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Please cite this article: RELATIONSHIP OF DEPERSONALIZATION AND
SUICIDALITY IN DEPRESSED PATIENTS
POVEZANOST DEPERSONALIZACIJE I SUICIDALNOSTI U DEPRESIVNIH
PACIJENATA
Authors: Suzana Tosić Golubović †*, Olivera Žikić†* , Violeta Slavković ‡, Gordana
Nikolić †*, Maja Simonović†*; Vojnosanitetski pregled (2017); Online First February,
2017.
UDC:
DOI: 10.2298/VSP161201023T
When the final article is assigned to volumes/issues of the Journal, the Article in Press
version will be removed and the final version appear in the associated published
volumes/issues of the Journal. The date the article was made available online first will be
carried over.
†* University of Nis, Medical Faculty, Department for psychiatry
†* Clinic for mental health protection, Clinical Centre Nis.
‡ Clinic for Psychiatry, Clinical Centre Nis.
Corresponding author with full address:
Suzana Tošić-Golubović,
Betovenova 21, Donja Vrežina
18000 Niš, Serbia
+381 18 571130
Fax: +381 18 4232 421
E-mail: suzanatosic67@gmail.com
Short title:
Depersonalization and suicidality in depression
Depersonalizacija i suicidalnost kod depresije
Abstract
Background/Aim Depersonalization is a considered to be the third leading symptom in
psychiatric morbidity The aim of this study was to investigate the correlation of
depersonalization and diferent patterns of suicidal behaviour in subjects suffering from
depresssive disorder. Methods. The whole sample consisted of 119 depressed patients
were divided in two groups: the first group od depressed patients with clinically manifested
depersonalization according Cambridge Depresonalisation Scale presented score ≥70, and
the second group whithout clinically manifested depersonalization symptomatology, or it
was on the subsyndromal level. Subsequently, these two groups were compared regarding
the suicidality indicators. Results: Depressed patients with depersonalization had
significantly higher scores for suicidal ideation, according to Scale for Suicide Ideation of
Beck, both active and passive, more often manifested suicidal desire, suicidal planning and
overall suicidality (p<0.000). Positive ideation, as a protective factor, was reduced in this
group (p<0.000). These patients had more previous suicide attempts (p<0.001) and family
history of suicides (p=0.004). Depressed patients with depersonalization eight times more
often had active suicidal desire, eleven times more often passive suicidal desire and five
times more often suicidal planing. Conclusions: Suicidal potential, manifested in various
patterns of suicidal behaviour among patinets suffering from depressive disorder with
clinically manifested depersonalization is prominent. It is necessary to pay particular
attention to depersonalization level, during diagnostic and treatment procedure od
depressed patients, having in mind that it may be associated with high suicidal potential.
Key Words: Depersonalization, Depression, Suicidal Ideation, Suicide, Risk factors
Sažetak
Uvod/Cilj. Depersonalizacija, uz anksioznost i depresiju spada medju tri najvažnija
simptoma psihijatrijskih poremećaja. Cilj istražvanja je utvrđivanje povezanosti
depersonalizacije i različitih oblika suicidalnog ponašanja kod depresivnih pacijenata.
Metode. Istraživanje je rađeno na grupi od 119 depresivnih pacijenata (21% muškog, 79%
ženskog pola). U istraživanju su korišćeni: Cambridge Depersonalization Scale (CDS),
Scale for Suicide Ideation of Beck (SSI) i Positive and Negative Suicidal Ideation
(PANSI). Na osnovu skora na CDS skali pacijenti su podeljeni na grupu pacijenata sa
depersonalizacijom (skor ≥70) i na grupu pacijenata bez depersonalizacije (<70). Ove dve
grupe komparirane u odnosu na indikatore suicidalnosti. Rezultati. Pacijenti oboleli od
depresije sa depersonalizacijom imali su signifikatno veći skor za suicidalne ideje po
Bekovoj skali za suicidalne ideje, češće su su manifestovali, kako aktivne, tako i pasivne
suicidalne želje, suicidalne planove i globalnu suicidalnost (p<0.000). Pozitivne ideje, kao
protektivni faktor, bile su redukovane u ovoj grupi ispitanika (prva grupa) (p<0.000). Ovi
pacijenti imali su više ranijih pokušaja suicida (p<0.001), kao i suicide u porodičnoj istoriji
(p=0.004). Depresivni pacijenti sa depersonalizacijom osam puta češće imaju aktivne
suicidalne želje, jedanaest puta puta češće pasivne suicidalne želje i pet puta češće
suicidalne planove. Zaključci. Suicidalni potencijal, manifestovan kroz različite obrazce
suicidalnog ponašanja obolelih od depresivnog poremećaja sa visokom depersonalizacijom
je prominentan. Neophodno je obratiti posebnu pažnju na nivoe izraženosti
depersonalizaije tokom dijagnostičkih i terapijskih procedura depresivnih pacijenata,
imajući u vidu da postojanje depersonalizacije može biti povezano sa visokim suicidalnim
potencijalom.
Ključne reči: Depersonalizacija, Depresija, Suicidalne ideje, Suicid, Faktori rizika
Introduction
There is a number of identified risk factors which can provide clinicians with a risk
profile for a suicide. Health professionals who are familliar to these risk factors can thereby
indentify potential at risk patients for further assessment of suicidality and preventive
measures (1).
Studies showed that some psychiatric disorders and conditions are related to high
suicide risk, especially mood disorders, psychotic disorders, anxiety disorders, some
personality disorders as well as substance abuse and dependence (particularly alcohol) (1-
4). Major depression is outlined as a particularly significant suicide risk factor because
even 50% of those who have made a suicde attempt were suffering from this disorder. In
addition to the diagnosis itself, the presence of specific symptoms occuring within the
depressive syndrome may be associated with an increased suicide risk.
On the other hand, depersonalization is a symptom considered to be the third on
the scale, in terms of frequency in psychiatric morbidity (just after anxiety and depression)
(5). However, it is often not recognized. According to data from literature, there is
relatively high prevalence of depersonalization symptomatology in depressive disorder (6-
8). The depersonalization symptomatology within depressive disorder was found in 4% of
patients in primarly care (9), 28% of outpatients (10) and even 60% of inpatients (1).
Due to very unpleasant experience, such as feeling that their own body, mental
processes and environment are strange and changed, or numbness of perceptive experience,
patients with depersonalization are occassionally apt to self-injuring which shortly
interrupts the horror of changed experience (12). Also, the depersonalization is associated
with increasing of suicidal ideation as well as suicidality in general. In the community-
based survey with 5000 participants, the authors found out that depersonalization and
Type-D personality are uniquely associated with suicidal ideations (13). In nonclinical
sample of 7905 participating surgeons, the presence of suicidal ideation was related with all
3 domains of burnout (emotional exhaustion, depersonalization, and low personal
accomplishment) and symptoms of depression (14).
Having in mind the aforementioned, as well as the fact that depersonalization very
often accompanies, i.e., is the associated symptom in depressive disorder, we wanted to
investigate the correlation of depersonalization and diferent patterns of suicidal behaviour
in subjects suffering from depresssive disorder.
Methods
The entire group comprised 119 patients, of both genders (25 males - 21%, 94
females -79%), The inclusion criteria for our crosssection study were: diagnosis of
depressive episode or recurrent depressive episode (F32.0-2, F33.0-2) according to ICD X,
age 18-65, primary education minimum,the absence of cognitive impairment or organic
couse of depression (F06.3), mental retardation, substance abuse disorders, a history of
seizures, the absence of serious medical (somatic) illnesses that were not considered well-
controlled. Patients with psychotic feature or hystory of (hypo)manic episodes, according
to ICD X, were excluded from our investigation. All study patients were consecutivly
addmited to hospital treatment at Psychiatry Clinic Gornja Toponica, or treated in
outpatient condition at Clinic for Mental Health Protection. All patients who passed
inclusion criteria were tested crossectionaly during treatment at mentioned psychiatry
institutions. All psychological assessments were focused on the areas of depression,
depersonalization and suicidality. Standard psychometric instruments employed included:
1. Cambridge Depersonalization Scale (CDS) (15) – was used to measure
depersonalization symptomatology intensity. Scores exceeding or equal 70 are the
indicators of clinically manifested depersonalization levels existence. It consists of 29
items.
2. Scale for Suicide Ideation of Beck (SSI) - Suicidality assessment scale(16),
comprised of 19 items. We can obtain three subscales active suicidal desire, passive
suicidal desire and specific suicidal plan as well as total score of suicidality. Higher scores
indicate greater level of suicidality.
3. Positive And Negative Suicidal Ideation (PANSI) (17) – It is a 14 item scale for
assessing suicidal thoughts. Data processing provides evidence about positive and negative
suicidal thinking.
All examined patients also responded to questionnaire items devised by the authors,
focused on their sociodemographic characteristics, as well as previous suicide attempts and
family history of suicide.
All 119 depressed patients were divided in two groups: the first group od depressed
patients with clinically manifested depersonalization according Cambridge
Depresonalisation Scale (15) presented score ≥70, and the second group whithout clinically
manifested depersonalization symptomatology, or it was on the subsyndromal level. Based
on this criteria, the first group with depersonalization comprised of 50 patients and the
second group without depersonalization, of 69 patients. Subsequently, these two groups
have been compared in regard to suicidality indicators.
The study was approved by the Regional Ethical Committee, all patients gave
written consent and the study was performed in full accordance with Declaration of
Helsinki (1965) and later revisions.
Within-and between-groups comparison were performed using The Statistical
Package for the Social Sciences, Version 17 (SPSS 17) in order to analyze the results.
Preliminary analysis was performed to ensure no violation of the assumptions of linearity
and normality. In order to determine whether the data were normally distributed, we used
the Kolmogorov - Smirnov test (KS-test). Data were expressed as mean ± SD, except for
non-Gaussian parameters, which were presented as median (range). We used Student’s t-
test for parametric data. For non-parametric data, we used χ2 test, Spearman’s rho, Mann
Whitney U, Phi and Odds ratio with confidence intervals. All reported p-values are exact
two-sided significance levels. Statistical significance was defined as p < 0.05.
Patients
Both groups did not significantly differ concerning gender, place of residence, age
and level of education (Table 1). In both groups, the majority of patients were females and
most of participants lived in urban environment (in town). The average age of patients in
the first group (with clinically manifested depersonalization) was 42.11 ± 11.817 and in the
second group (without clinically manifested of depersonalization) 44.93 ± 11.199 years
(t=1.188, df=117, p=0.237). Most of the patients have a standing partner. Patients with
intermediate level of education dominated in both groups.
Results
Suicidal ideation
Positive ideation, i.e., positive attitudes to life opposite to suicide was more
intensive in the second group (mean rank 72.29). There was a statistically significant
difference compared to the first group with depersonalization, where the mean rank was
43.04 (Mann Whitney U=877.0, p<0.0001). Depersonalization score was in negative
correlation with positive suicidal ideation and correlation was on a significant statistical
level (Spearman's rho = - 0.452, p<0.0001).
In the first group with depersonalization, the negative ideation mean rank was
77.13, while in the second group it was 47.59 with statistically significant difference
between groups (Mann Whitney U=868.5, p<0.0001). Depersonalization score was in
positive correlation with negative suicidal ideation and Spearman's rho correlation was on
statistical significant level (Spearmans rho = 0.569, p<0.000).
Suicidal desire
Suicidal desire, both active and passive, was more often presentes among depressed
patients with depersonalization-the first group.
(Table 2. about here)
Active suicidal desire was present in 82% of patients with depersonalization (the first
group), but in 36,2% in the second group-depressed patients without depersonalization
(p<0.0001). Passive suicidal desire was present in 80% in first group patients with
depersonaliztation while in patients without depersonalization (second group), it was in
26,1%. Odds ratio was very high. Odds ratio for active suicidal desire was 8.0 and for
passive suicidal desire 11.3.There was a highly significant assotiation between the level of
depersonalization and suicidal desire (active and passive).
(Table 3. about here)
Sucidal planning
Suicidal planing was more often reported by patients from the first group with
depersonalization. Fiftysix percents of the first group-depressed patients with
depersonallization had suicidal planing as well. In the second group (without
depersonalization) were 20.3% patients with this pattern of suicidality. Odds ratio between
depersonalization and suicidal planing was 5. The correlation between the level of
depersonalization and suicidal planing was positive and statistically significant (Table 3).
Overall suicidality
Similar to previous results and in accordance with it, the presence of suicidality
in general was more often reported within the first group with depersonalization (Table 2).
There was a significant association between depersonalization and suicidality (Odds ratio
6.6) (Table 2). Correlations between level of depersonalization and general suicidality
scores was positive, and on statistically significant level (Table 3).
Previous suicide attempt
One of the suicidality risk factors was previous suicide attempt. Some authors
describe it as the most important risk factor (15). In our study, higher percentage of
subjects who have previously attempted suicide was in the first group with
depersonalization (even 50%), while in the second group it was almost two-thirds less
(18.8%). After the statistical processing, we obtained statistically significant difference
between the groups (Table 1).
Family history of suicide
Regarding to the family history, the groups differed on the statistically significant
level (Table 1). In the first group with depersonalization, 32% of patients reported family
history for suicide, while in the second group with low depersonalization it was the case in
10.1% of subjects.
Discussion
Suicidal ideation refers to thoughts, fantasies, ruminations and preocupations about death,
self harm and self inflicted death (18). Suicidal ideation is presented through two variables
positive and negative ideation. Our study showed that depressed patients with high
depersonalization (≥70, according to Cambridge Depresonalisation Scale), had significant
reduced positive thinking about life, therefore reduced positive ideation, as an important
suicide protective factor. At the same time, negative ideation was significant increased,
reflecting the lack of motive for life and giving advantage to suicide as a possible way of
resolving the actual situation. Our results are in accordance with Yoshimasua study (19), in
part that refferes on male subjects. Based on Spearmans rho coeffitients, increasing of
depersonalization in depressive disorder, resulted with the reduction of positive ideation
intensity and increasing of negative ideation among our study patients. Suicide ideas could
be active, when a person clearly wishes to commit suicide, or passive, when a person does
not try to protect himself/herself in situations potentially dangerous for their life. This
pattern of suicide behaviour, was significantly more expressed in depressed patients with
clinically relevant depersonalization, 80% vs. 20% (among patients without
depersonalization). Depressed patients with depersonalization eight times more often
presented active suicidal desire and eleven more often had passive suicidal desire
(according to odds ratio), indicating the strong assotiation between depersonalization and
suicidal desire (active and pasive), as one of the suicide risk factors.
Our study patients who suffered from depression with concomitant
depersonalization five times more often had suicidal planing (according to odds ratio),
indicating that suicidal intent (suicidal plan making), as a serious risk factor, was also
strongly associated with depersonalization.
The presence of overall suicidality was in accordance with previous results,
indicating that depressed patients with depersonalization five times more often had any
type of suicidality. The similar conclusion was derived from the results of the previous
studies (18, 20), that reported the higher risk if suicidal thoughts are present for longer time
and occurre more frequently (18, 20). Our study results also indicated that, in order to
assess suicidality, it is very important to establish not only the existance of suicidal
thoughts, but also to determine their intensity, as a prominent suicidal risk factor.
There are some other facts which indicating and raise suicidal risk. First of all,
previous suicide attempt(s) is a bad prognostic sign, because of great risk of reattempting or
commiting suicide (21, 22). In our study almost triple number of patients with previous
suicide attempt(s) were in the group with depersonalization, indicating that the combination
of previous attempt(s) additionally increases the suicide risk and potential mortality. At the
same time, the presence of family history for suicide was also triple in the group with
depersonalization, so that had been considered as a significant risk factor by some authors
(23, 24). Mentioned two additional risk factors, previous suicidal attempts and family
history of suicide, have further negative impact on global suicidality pattern in depressed
patients with concomitant depersonalization. The association between depersonalization
and suicidality in depressive disorder was significant and may be considered as a bad
prognostic sign.
However, there are some study limitations: like small sample size, cross section
study design, the lack of explanation what kind of relationship it is – direct or indirect
among depersonalization and suicidality. In order to find out an answer, we should perform
further analysis that could uncover the main road of this association (such as mediation
analysis) as well as with the larger sample. Our findings are based on a limited number of
patients, which makes our data vulnerable to statistical biases and increases the threshold
for obtaining statistical significance between groups. Data reaching statistical significance
may therefore be viewed as highly indicative, though not conclusive.
Conclusions
Suicidal potential in persons affected by depressive disorder with clinically
manifested depersonalization is prominent. Concomitant pathological depersonalization
among depressed patients was associated with the increase of suicidal ideas, active and
pasive suicidal desire and suicidal planning. Suicide attempts, as well as family history of
suicide among depressed patients with depersonalization, additionaly increase suicide risk.
It is necessary to pay particular attention to depersonalization level, during diagnostic and
treatment procedure od depressed patients, having in mind that it may be associated with
high suicidal potential.
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Table 1: Socio-demographic data
I group with
depersonalization
II group without
depersonalization
χ2
Df
P
N
%
N
%
1
Gender
1.303
1
0.265
Female
42
84%
52
75.4%
Male
8
16%
17
24.6%
2
Place of residence
0.531
1
0.767
Town
26
52%
40
58%
Village
19
38%
24
34.8%
Big village
5
10%
5
7.2%
3.
Partnership
2.628
1
0.165
With partner
35
70%
57
82.6%
Single
15
30%
12
17.4%
4.
Education
2.836
1
0.425
Low (8 years)
6
12%
13
18.8%
Medium (12 years)
36
72%
46
66.7%
Higher (15 years)
4
8%
2
2.9%
High (16-18 years)
4
8%
8
11.6%
5
Previous suicide attempt
12.950
1
<0.001
Yes
25
50%
13
18.8%
No
25
50%
56
81.2%
6.
Family history of suicide
8.881
1
0.004
Yes
16
32%
7
10.1%
No
34
68%
62
89.9%
Table 2: Suicidal behavior and depersonalization
I group with
depersonalization
II group without
depersonalization
χ2
df
P
Odds
ratio
95%
Confidence
interval
N
%
N
%
1
Active
suicidal desire
24.585
1
<
0.001
8.0
3.350-
19.188
Yes
41
82%
25
36.2%
No
9
18%
44
63.8%
2
Passive
suicidal desire
37.728
1
<
0.001
11.3
4.716-
27.258
Yes
40
80%
18
26.1%
No
10
20%
51
73.9%
3
Specific
suicidal plan
16.189
1
<
0.001
5.0
2.224-
11.239
Yes
28
56%
14
20.3%
No
22
44%
55
79.7%
4
General
suicidality
20.416
1
<
0.001
6.7
2.804-
15.872
Yes
41
82%
28
40.6%
No
9
18%
41
59.3%
Table 3: Association of suicidal behavior and depersonalization among the first group of patients
Phi
P
1
Active suicidal desire
0.455
< 0.001
2
Passive suicidal desire
0.532
< 0.001
3
Specific suicidal plan
0.369
< 0.001
4
General suicidality
0.414
< 0,.01
5
Previous suicidal attempts
0.330
< 0.001
6
Family history of suicide
0.273
0.004
Received on December 01, 2016.
Revised on January 17, 2017.
Accepted on January 19, 2017.
Online First February, 2017.
