2.2. Clinical assessment

PMS status was evaluated using the shortened version of the Premenstrual Assessment Form (PAF). It is a validated self-assessing questionnaire identifying changes in mood, behavior and physical well-being during the premenstrual period (from 1 to 14 days prior to the onset of menses). Patients self-reported actual changes when they were in their premenstrual period, or common changes that occurred in their past three menstrual cycles. This questionnaire contains 33 items [27]. Cronbach’s Alpha for internal reliability revealed a high alpha (0.98). A score of 115 or above suggests moderate to severe symptoms of PMS [27, 28]. As a result we used this cut-off to evaluate PMS diagnosis.

PMDD status, a severe form of PMS characterized by more restrictive criteria and a predominance of emotional and behavioral symptoms [29, 30], was assessed using DSM 5 items from the PAF-shortened form [27, 28]. See supplementary material for details about these criteria.

Six personality dimensions previously involved in suicidal vulnerability were assessed [31–33]:

Impulsivity was assessed using the Barratt Impulsivity Scale—tenth version (BIS 10) [34]. This scale contains 34 items rated from 0 to 4. It is subdivided into three different subscales: non-planning, motor, and cognitive impulsivity.

Aggressiveness/hostility was assessed using the Buss-Durkee Hostility Scale (BDHI) [35]. It is a 75 true-false items inventory consisting of the following subscales: Assault, Indirect Hostility, Irritability, Negativism, Resentment, Suspicion, Verbal Hostility, and Guilt. The total score consists in the sum of all subscale scores and ranges from 1 to 75.

Anger was assessed using the Spielberger State-Trait Anger Expression Inventory (STAXI) [36, 37]. It is a self-assessment scale with 44 items designed to evaluate a person’s anger level. Each item is essentially a statement to describe one’s emotions when feeling angry. Each item is assessed by a four-point scale (1 = no anger; 4 = maximum anger). We focused on the trait anger dimension in the present study.

Hopelessness was assessed using the Beck Hopelessness Scale (BHS) [38, 39]. It is a self-report scale consisting of 20 true-false statements. The score ranges from 0 to 20.

Affect intensity was assessed using the 44 items of the Affect Intensity Measure Scale [40]. This self-report scale examines affect intensity via the responses given to emotional reactions to typical life events. Each item is rated on a six-point scale.

Affect lability was assessed using the Affect Lability Scale (ALS)-54 items [41]. This self-report scale assesses changeability or shifts in affect. Items are scored on a four-point scale ranging from 1 = not like me at all, to 4 = very much like me.

Axis-I DSM-IV diagnoses were assessed using the Diagnostic Interview for Genetics Studies (DIGS) [42] or the Mini International Neuropsychiatric Interview (MINI] [43]. We used either DIGS or MINI depending on the assessment but not both diagnostic interviews at the same time. We used this procedure to simplify the diagnostic assessment in patients who made serious or violent attempts (DIGS is more time-consuming). Lifetime diagnoses were determined using a best-estimate procedure: the psychiatrist in charge of the patient’s care established the diagnosis based on the MINI or DIGS interview, medical records and, when available, information from relatives [44]. Psychiatric comorbidities included lifetime diagnostic of depression and bipolar disorder, anxiety disorders, substance/alcohol use disorder, current depression severity, and tobacco consumption. Current depressive symptom levels were assessed using the Beck Depression Inventory-II (BDI-II) [45].

Sociodemographic variables were age, marital status (unmarried/married), present occupation (unemployed/employed), educational attainment (< 12 years of study /≥12 years of study), and hormonal birth control.