Beruflich Dokumente
Kultur Dokumente
Research report
a r t i c l e i n f o
a b s t r a c t
Article history:
Received 19 March 2012
Received in revised form
16 May 2012
Accepted 30 May 2012
Available online 24 August 2012
Keywords:
Sensation seeking
Adolescence
Suicidal ideation
Suicide attempts
Depression
Substance use
1. Introduction
Heightened levels of sensation seeking in adolescence have
been consistently associated with increased participation in risktaking behaviors ranging from reckless driving to unsafe sex
(Arnett, 1990, 1996; Roberti, 2004; Wagner, 2001). High levels
of sensation seeking have been particularly implicated in earlier
onset and greater severity of substance use problems (Bekman
et al., 2010; Crawford et al., 2003; Macpherson et al., 2010). While
for the most part these studies have not addressed suicidal
behavior, some justication has been found for including suicidal
behavior within the spectrum of risk-taking behaviors. In a
community probability sample of 917 year olds, suicidal ideation and suicide attempts were associated with risk-taking
n
Correspondence to: NYS Psychiatric Institute, Columbia University, 1051
Riverside Drive, Unit 72, New York, NY 10032, USA.
Tel.: 1 212 543 5329; fax: 1 212 543 5966.
E-mail address: gouldm@nyspi.columbia.edu (M.S. Gould).
0165-0327/$ - see front matter & 2012 Elsevier B.V. All rights reserved.
http://dx.doi.org/10.1016/j.jad.2012.05.058
215
2. Methods
2.1. Participants
Study participants were recruited from ve public highschools and one private school in Nassau, Suffolk, and Westchester counties in New York State from 2002 to 2004. These schools
were part of a study examining possible iatrogenic effects of
asking about suicide in a school screening program (Gould et al.,
2005). A total of 3635 students were eligible for participation;
2342 (64.4%) participated in the study. Reasons for nonparticipation included parental refusals (61.9%), student refusals (14.3%),
and absences (23.7%). There were no signicant differences in
demographics between participants and nonparticipants.
Self-report questionnaires, including the sensation seeking
scale, were administered as a part of a 2-day screening procedure.
The 2189 participants who completed day 2 of the survey were
included in the current study. Of those, 41.6% were female and
81.9% were Caucasian, 4.7% Black, 8.0% Hispanic, 3.2% Asian, and
3.1% other. The mean age of the participants was 14.80 (1.18)
with a range of 13 to 18. A total of 153 participants (6.5%)
216
2.2. Measures
The assessment time frame was the past 4 weeks, with the
exception of suicide attempts (lifetime) and sensation seeking
(ongoing trait).
Demographic questionnaire: the questionnaire elicited information on age, grade, gender, ethnicity, and household composition.
Sensation seeking: the Brief Sensation Seeking Scale-4 (BSSS-4)
contains four items derived from the Brief Sensation Seeking Scale
(BSSS) (Hoyle et al., 2002), an eight-item battery tailored for adolescents by adapting items from the Sensation Seeking Scale-V (SSS-V)
developed by Zuckerman et al. (1978). Each one of the four items
comprising the BSSS-4 pertains to one of the four original SSS-V
subscales: I would like to explore strange places (Experience
Seeking); I like to do frightening things (Thrill and Adventure
Seeking); I like new and exciting experiences, even if I have to break
the rules (Disinhibition); and I prefer friends who are unpredictable (Boredom Susceptibility). The BSSS-4 uses a 5-point Likert-type
scale, anchored by Strongly Disagree to Strongly Agree. This fouritem scale correlates highly (r0.89) with the BSSS, which itself has
been found to have strong construct validity (Stephenson et al., 2003).
In addition, it has been demonstrated to be both valid and reliable in
a national survey of adolescent drug use (Hornik et al., 2002). In the
current study, the four-item scale came from a telephone survey, The
National Annenberg Survey of Youth (NASY), conducted by the
Annenberg School of Public Policys Institute for Adolescent Risk
Communication (Romer, 2003). The only difference between this
four-item scale and the BSSS-4 was that the items were presented in
a 4-point Likert-type scale ranging from 0 (Strongly Disagree)
to 3 (Strongly Agree). The total score ranged from 0 to 12.
In our study, the internal reliability coefcient for the sensation
seeking scale was high (Cronbachs alpha0.75). There is no established cutoff point for the BSSS-4. To allow for the calculation of odds
ratios, we dichotomized the sensation seeking scale by classifying as
high sensation seeking those students whose scores placed them in
the highest quartile (Q4); and as low sensation seeking those with
scores in the lower three quartiles. The same dichotomization has
been used in previous epidemiological studies of novelty seeking
(Fergusson et al., 2000). The cutoff point of 48 established using this
method also coincided with one standard deviation above the mean,
based on our samples distribution of scores (Mean5.84; SD 2.95).
Depression: the Beck Depression Inventory (BDI-IA; Beck and
Steer, 1993) contains 21 items that assess cognitive, behavioral,
affective, and somatic components of depression. Loss of libido was
not assessed. The responses for each question range from 0
(symptom is not present) to 3 (symptom is severe). The BDI has
been used in 4200 studies, and has demonstrated good reliability
(Strober et al., 1981; Teri, 1982) and validity (Roberts et al., 1991) for
use with an adolescent sample. For the total score, the suicidal
ideation question was omitted lowering the maximum score to 57;
therefore the cutoff point for depressed versus not depressed was
adjusted from 16 to 15, as recommended to detect possible depression in normal populations (Beck and Steer, 1993).
Substance use problems: the Drug Use Screening Inventory
(DUSI) (Tarter, 1990; Tarter and Hegedus, 1991; Tarter et al.,
1992) is designed to screen for alcohol or drug use and problems
among teenagers and has demonstrated good reliability, discriminate validity, and sensitivity and has published normative cutoff
scores (Kirisci et al., 1995, 1994; Tarter et al., 1994, 1997, 1992,
1995). A total score combines all 15 items from the substance use
scale (assessing the degree of involvement and severity of consequences from alcohol and drug use), three alcohol or drug items on
the school performance adjustment scale, and one additional
aggression item assessing the clinically predictive problem of breaking things or getting into ghts while under the inuence of alcohol
or drugs (Shaffer et al., 1996). A cutoff point of Z5 was used to
dichotomize scores based on the recommended cutoff points,
roughly corresponding to 10% of the sample (Kirisci et al., 1995).
Suicidal ideation: suicidal ideation was assessed by the 15-item
Suicidal Ideation Questionnaire (SIQ-JR), and the suicide item on
the BDI-IA. The SIQ-JR is designed for large-scale, school based
screening of adolescents (Reynolds, 1988). The 15-item questionnaire uses a seven-point Likert-type scale, ranging from 0 (I
never had this thought) to 6 (This thought was in my mind
almost every day), assessing the frequency of specic suicidal
thoughts during the past month. It assesses a wide range of
thoughts related to death and dying, passive and active suicidal
ideation, and suicidal intent. The SIQ-JR has demonstrated criterion validity (King et al., 1993; Reynolds, 1990; Reynolds and
Mazza, 1999) construct validity in clinical samples (King et al.,
1993; King et al., 1997), and predictive validity (Keane et al., 1996).
Suicidal ideation was considered serious suicidal ideation if the
adolescent scored 31 or higher on the SIQ-JR, scored 5 or 6 on two or
more of the six critical SIQ-JR items (Reynolds, 1988), or
responded with either of the two most serious response options of
the BDI suicide item.
Suicide attempt history: seven questions asking about lifetime
and recent suicide attempts were derived from the depression
module of the Diagnostic Interview Schedule for Children (DISC;
Shaffer et al., 2000) and an earlier suicide screen (Shaffer et al.,
2004). These items have demonstrated good construct validity
(Gould et al., 1998; Shaffer et al., 2004). The questions inquired
about the occurrence and details of lifetime and recent suicide
attempts. The adolescent was considered to have an attempt history
if he or she reported any past attempt, regardless of timing, injury,
or medical attention, because there is no evidence that injury or
need for medical attention is a clear indication of severity of
attempts among adolescents.
217
Table 1
Association of sensation seeking with demographic variables.
Low SS group (n 1778)
Gender
Boys
Girls
n
1266
907
% (n)
% (n)
80.6 (1021)
83.5 (757)
19.4 (245)
16.5 (150)
Grade
9b
10
11
12
n
1126
549
312
186
%
%
%
%
81.8
82.9
80.8
80.6
18.2
17.1
19.2
19.4
Age
(n)
(n)
(n)
(n)
(921)
(455)
(252)
(150)
a
b
ORa
(95% CI)
1.27n
(1.0021.61)
0.90
0.93
0.89
(0.671.21)
(0.651.34)
(0.571.38)
Mean (SD)
Mean (SD)
b (s.e.)
14.78 (1.18)
14.87 (1.18)
0.04 (0.05)
0.398
(205)
(94)
(60)
(36)
218
Table 2
Association of sensation seeking with depressive symptoms, substance use problems, serious suicidal ideation, and suicide attempts.
Low SS group (n 1778)
% (n)
% (n)
Depressive symptoms
9.7 (172)
22.4 (88)
5.2 (93)
14.9 (59)
2.7 (48)
8.1 (32)
Suicide attempts
3.0 (54)
8.9 (35)
2.90nnn
(2.163.89)
3.25nnn
(2.274.64)
3.43nnn
(2.155.49)
3.47nnn
(2.205.46)
1.73n
(1.012.94)
2.08nn
(1.263.41)
2.81nnn
(1.734.57)
2.79nnn
(1.744.47)
suicidal ideation was 2.2% and 6.6% for the low and high sensation
seeking groups, respectively. In the group with substance use
problems, the percentage of students who reported serious
suicidal ideation was 12.0% and 16.9% in the low and high
sensation seeking groups, respectively.
Sensation seeking did signicantly interact with substance use
problems in its association with suicide attempt history
(b(s.e.) 1.06(0.52), p o0.05). In the group without substance
use problems, the percentage of students who reported suicide
attempts was 2.3% and 7.1% for the low and high sensation
seeking groups, respectively. In the group with substance use
problems, the percentage of students who reported suicide
attempts was 17.2% and 18.6% for the low and high sensation
seeking groups, respectively. The association between suicide
attempt history and sensation seeking was statistically signicant
only in the group of students without substance use problems
(OR3.90(95%), CI: 2.266.71), and not in the group of students
with substance use problems (OR 1.16(95%), CI: 0.452.95).
rather than depressed (Crowe et al., 2006), and adolescent depression manifests with greater comorbidity, especially with anxiety
disorders, disruptive behaviors, drug abuse problems, other risktaking behaviors (Angold and Costello, 1993; Fergusson and
Woodward, 2002; Ginicola, 2007; Rohde et al., 1991; Testa and
Steinberg, 2010). Moreover, onset of depression during childhood
and young adolescence increases the risk of a subsequent transition
into the bipolar spectrum (Geller et al., 1994, 2001). Bipolar
disorders are associated with high suicide risk (Kelly et al., 2002;
Lewinsohn et al., 1995), and with higher levels of novelty seeking
and impulsivity in adolescents (Gilbert et al., 2011; Nandagopal
et al., 2011; Olvera et al., 2009; Tillman et al., 2003).
In our sample, adolescents with depressive symptoms and
high sensation seeking showed the highest rates of suicidal
ideation and suicide attempts. The conjunction between sensation seeking, depression and suicidal behavior might be understood as signaling an underlying temperamental dysregulation,
which usually manifests at a subclinical level and is considered a
marker for bipolarity (Akiskal, 1995; Akiskal et al., 2003;
Kochman et al., 2005). Further exploration of the role of sensation
seeking among depressed adolescents as a potential indicator of
emergent bipolarity is warranted.
It is notable that the association of sensation seeking with
suicidal ideation and suicide attempts remained signicant when
controlling for depressive symptoms. This nding is consistent
with research linking novelty seeking and impulsivity with higher
risk of suicidal behavior after controlling for depression
(Fergusson et al., 2000; McGirr et al., 2008). The independent
association of sensation seeking with suicide attempts might be
understood within the framework of the Interpersonal-Psychological Theory of Suicide (Joiner, 2005; Ribeiro and Joiner, 2009;
Smith and Cukrowicz, 2010). According to this theory, to attempt
suicide a person has to have the acquired capability for suicide
as well as the desire to die. This capability is a condition involving
a heightened degree of fearlessness and pain insensitivity such
that the pain and fear entailed by a suicide attempt no longer
function as deterrents; it is acquired through repeated exposure
and habituation to painful, fearsome and otherwise provocative
events, y (Joiner et al., 2009).
High sensation seekers tend to be exposed to variety of
intense, provocative, and dangerous situations, and suffer from
a high rate of accidental injuries (Arnett, 2002; OJile et al., 2004;
Osborn et al., 2009). Repeated engagement in high risk activities
may result in a progressive habituation to fear and physiological
pain, and, over time, in a higher tolerance for pain and a sense of
fearlessness in the face of death (Joiner et al., 2009). However,
this model does not seem able to account for the association we
also found between high levels of sensation seeking and increased
risk of suicidal ideation.
Our nding regarding substance use extends a previously
published nding (Bolognini et al., 2002) that sensation seeking
contributes to the risk of suicide attempts over and above the
contribution of drug abuse. We similarly found a signicant
association between sensation seeking and both suicidal ideation
and suicide attempts when controlling for substance use problems; however, when we explored the interaction effect, substance use problems moderated the association between
sensation seeking and suicide attempts, such that the association
was only signicant in the group without substance use problems. This result contradicts the ndings of a study of sensation
seeking, alcohol/drug use, and risky sexual behavior, in which
investigators found that the personality dimension of sensation
seeking increased the positive situational effects of both alcohol
and drug use prior to sex on frequency of unprotected sex with
partners (Newcomb et al., 2011). We likewise would have
expected to nd a cumulatively greater risk of suicidal behavior
219
in the group with both high sensation seeking and substance use
problems. We interpret our nding as indicating that in the case
of suicidal behavior, substance use problems and high levels of
sensation seeking may play parallel roles in promoting behavioral
disinhibition; in other words, their contributions to suicide risk
may be overlapping rather than additive. Gould et al. (1998)
found that substance abuse/dependence independently differentiated suicide attempters from ideators in a sample of 1285 youth
ages 917. It may be that in adolescents with substance use
problems, substance use facilitates the acquisition of the capability for suicide, while in adolescents without substance use
problems, high levels of sensation seeking ll the same role,
although to a somewhat lesser degree.
4.1. Limitations
The selection of schools was constrained by the design of our
earlier study (Gould et al., 2005). The schools were suburban and
predominantly white, limiting the generalizability of our ndings
to urban and more ethnically or socioeconomically diverse
populations. The participation rate was low, as is common in
suicide-screening protocols (Shaffer et al., 2004). Although there
were no signicant differences between participants and nonparticipants in demographic factors (e.g., sex, grade level, ethnicity), we were unable to assess differences in clinical factors (e.g.,
risk status, BDI-IA and SIQ-JR scores). In addition, in our study we
only included students who completed both days of the screening
program. Those who did not complete the second day were
slightly older and reported signicantly more substance use
problems; no other differences were found. Given the low rates
of non-white students, we have not considered differences by
ethnicity.
Additionally, there are other constructs which may have
implications both for sensation seeking and for suicidal behavior,
such as conduct disorder, ADHD, bipolar disorders, and borderline
personality disorder, that we did not assess and therefore could
not control for. It would be useful in a future study to assess a
wider range of psychiatric problems in order to clarify the nature
of the association between sensation seeking and depression.
220
Conicts of Interest
None of the authors have conict of interest/nancial disclosures.
Acknowledgments
This study was supported by NIMH Grant, R01-MH64632. The rst author is
currently supported by a Grant from Alicia Koplowitz Foundation, Spain.
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