Attachment predicts treatment completion in an eating disorders partial hospital program among women with anorexia nervosa

The goal of this study was to examine if attachment theory can provide a framework for understanding treatment completion in an eating disorders partial hospital program among women with anorexia nervosa (AN). Attachment was measured using the Attachment Styles Questionnaire (Feeney, Noller, & Hanrahan, 1994). As hypothesized, self-reports of high avoidant attachment predicted noncompletion of treatment for those with AN binge-purge subtype (ANB). However, this relationship did not emerge for those with AN restricting subtype (ANR). Also as hypothesized, self-reports of high anxious attachment predicted completing treatment for those with ANB but not for those with ANR. For completers with ANB and ANR, the program was helpful in increasing body weight and lowering drive for thinness, body dissatisfaction, interpersonal problems, and depression. Attachment avoidance, characterized by devaluing one's need for relationships, may be a contraindication for group-based partial hospital treatment of ANB. Attachment anxiety, characterized by high preoccupation with relationships, may facilitate remaining in treatment for those with ANB.     

Psychopathology of adolescent suicide: hopelessness, coping beliefs, and depression

Two studies of adolescents examined the relation of several cognitive variables and depression to suicide-related behaviors. Study 1 compared hopelessness and depression in 281 high school students. Unlike research with adults, depression was significantly related to suicidal behaviors, even after hopelessness was statistically controlled. When depression was controlled, hopelessness was unrelated to suicidal behaviors for boys and only modestly related for girls. Study 2 examined depression, hopelessness, survival-coping beliefs, fear of social disapproval, and social desirability in relation to suicidal behaviors in 53 male juvenile delinquents. Again, hopelessness did not account for a significant proportion of the variance in suicide. Depression was uniquely related to past suicide attempts. Survival-coping beliefs were associated with self-predicted future suicide and other suicidal behaviors. Survival-coping beliefs are discussed as a cognitive buffer to suicidal ideation in adolescence.     

Suicide Ideation among Adolescent American Indians: An Application of General Strain Theory

The objective of this study is to compare suicidal thoughts among American Indian/Alaskan Natives (AI/AN) to a series of non-AI/AN comparison groups, using data from the National Longitudinal Study of Adolescent to Adult Health. This study uses general strain theory as the guiding framework for understanding differences between racial groups in their suicidal ideation. A statistically significant difference is present between AI/AN and comparisons in suicidal ideation. The factors that may explain these differences addressed in this study include: alcohol abuse, exposure to suicidal behavior of friends and family, depression, and gun access. Implications for prevention and treatment are discussed.     

The Gender Paradox in Suicide

In most Western countries females have higher rates of suicidal ideation and behavior than males, yet mortality from suicide is typically lower for females than for males. This article explores the gender paradox of suicidal behavior, examines its validity, and critically examines some of the explanations, concluding that the gender paradox of suicidal behavior is a real phenomenon and not a mere artifact of data collection. At the same time, the gender paradox in suicide is a more culture-bound phenomenon than has been traditionally assumed; cultural expectations about gender and suicidal behavior strongly determine its existence. Evidence from the United States and Canada suggests that the gender gap may be more prominent in communities where different suicidal behaviors are expected of females and males. These divergent expectations may affect the scenarios chosen by females and males, once suicide becomes a possibility, as well as the interpretations of those who are charged with determining whether a particular behavior is suicidal (e.g., coroners). The realization that cultural influences play an important role in the gender paradox of suicidal behaviors holds important implications for research and for public policy.     

The cycle of schizoaffective disorder, cognitive ability, alcoholism, and suicidality

In this study we investigated the putative role of cognitive dysfunction, diagnosis (schizoaffective versus schizophrenia disorder), and alcoholism as risk factors for suicidal behavior among individuals with DSM-TV schizophrenia or schizoaffective disorders. Subjects received cognitive tests and medical records were reviewed for evidence of a history of suicide attempts or suicidal ideation. Discriminant analysis was used to identify cognitive test performance measures that distinguished those with versus those without suicidal behavior. None of the cognitive measures discriminated between the two groups. The rates of suicidal behavior (suicidal ideation and suicide attempts) did not differ between participants with versus those without comorbid alcohol use. An association was found between suicidal behavior and the diagnosis of schizoaffective disorder. It was concluded that the history of prominent mood syndromes characteristic of schizoaffective disorder contributes to increased risk of suicidal behaviors. Cognitive dysfunction and/or alcoholism did not contribute additionally to risk in this study.     

The Impact of Exposure to Peer Suicidal Self‐Directed Violence on Youth Suicidal Behavior: A Critical Review of the Literature

There is considerable evidence that being exposed to the suicide or suicidal behavior of another can increase the risk for suicide. Significant relationships between media coverage and youth suicide have been documented in the professional literature. Exposure to familial suicidal behavior has also been established as a risk factor for youth suicidal behavior; However, peer suicide exposure is not as clear cut as research results in this area have been mixed. In the current paper the empirical literature focused on the associations between exposure to peer suicides and suicide attempts and youth suicidal behavior is critically reviewed. Effect sizes were computed for each of the 23 studies included in the review to allow for cross‐study comparisons. The results demonstrate that having a friend or acquaintance attempt suicide is significantly related to risk for suicidal thoughts and behavior. However, the support for the relationship between the suicide of a peer and youth suicidal behavior was less consistent. Implications for clinical practice and suicide postvention as well as areas of future research are discussed.     

Self-Reported Interoceptive Sensibility Does Not Moderate the Relationship Between Eating Disorder Symptoms and Suicidal Thoughts and Behaviors

Past research has demonstrated a strong relationship between eating disorders (EDs) and suicidality (i.e., suicidal thoughts, plans, and attempts), and preliminary work within the framework of the interpersonal psychological theory of suicide (Joiner, 2007) suggests that potentially painful ED behaviors (binge eating, purging, fasting, excessive exercise) may contribute to increased risk of suicide through heightened pain tolerance and increased capability of suicide. However, additional explanations are needed for why only some individuals with EDs actually engage in suicidal behaviors (i.e., attempt suicide), whereas others do not. A growing body of literature suggests that interoceptive deficits (a disconnection from one’s own bodily sensations and emotions; IDs) might be a factor linking eating disorders and suicide. To better understand this relationship, the current study tests the moderating effects of self-reported IDs on the relations between ED behaviors and suicidality and past suicide attempts in a transdiagnostic ED sample (N = 181). We hypothesized that ED behaviors would directly relate to suicidality, but that IDs would moderate the relationship between ED behaviors and past suicide attempts, such that those high in IDs would demonstrate a stronger relationship between ED behaviors and suicide attempts. Contrary to our hypothesis, IDs did not moderate the relationship; instead, fasting and purging had significant and strong main effects on suicidality and past suicide attempts without moderation effects. Results suggest that fasting and purging may be important ED behaviors to consider in the relationship between EDs and suicidality. Future directions include further examining the relationship between IDs, suicidality, and EDs using measures of IDs that better encompass physical (as opposed to emotional) aspects of IDs.     

Is Exposure to Suicide Beyond Kin Associated with Risk for Suicidal Behavior? A Systematic Review of the Evidence

Suicide bereavement and postvention literature often espouses risk for subsequent suicidal behavior among those previously exposed to a suicide death. Most often risk is discussed in relation to kin; however, many more individuals are exposed to suicide, and the impact of this exposure is important to understand in relation to targeting postvention. This review examined the research literature (1990–2014) to determine the evidence base for risk among those exposed to suicide. The findings demonstrate that risk of suicidal behaviors among those exposed to the suicide is significantly higher than those unexposed. These results are discussed within the context of current research in the field of postvention, and suggestions for future research are suggested.     

Hope and the Interpersonal‐Psychological Theory of Suicidal Behavior: Replication and Extension of Prior Findings

The interpersonal‐psychological theory of suicidal behavior (IPTS; Joiner, 2005) posits that suicidal behavior occurs when an individual has a desire for death (due to the combination of perceived burdensomeness and thwarted belongingness) in addition to an acquired capacity for suicide, which is present when the individual has a low fear of death and high pain tolerance. Previous research has demonstrated an expected negative relation between trait hope and perceived burdensomeness and thwarted belongingness, as well as a more perplexing finding that hope is positively associated with the acquired capability. In a sample of 230 college students, measures of the three components of the IPTS were administered, along with measures of hope, depression, and painful and/or provocative events. Hierarchical regression analyses replicated the previously found associations between hope and burdensomeness and belongingness while controlling for depression and demographic variables. The positive association between hope and acquired capacity was also replicated, but a mediation analysis demonstrated that the effect was statistically accounted for by distress tolerance. The results further support the incremental validity of hope as a consideration in suicide risk assessments and suggest that hope may serve as a protective factor with respect to suicidal desire.     

National differences in intelligence and population rates of suicidal ideation, suicide plans, and attempted suicide

Population rates of suicidal ideation, suicide plans or attempted suicide from three independent multinational epidemiological surveys (the WHO/EURO and WHO SUPRE-MISS studies and a third one) were not significantly associated with national IQ figures. This result conflicts with previous evidence from cross-national studies (by Lester and by Voracek) of a positive ecological correlation between level of national intelligence and rates of completed suicide. Across nations, the indicators for the prevalence of suicidal behavior also lacked close correspondence with suicide rates, which may be due to the higher unreliability of assessing covert suicidal behavior (suicide ideas, thoughts, plans, and, to a lesser extent, also suicide attempts) as compared to suicidal behavior that is indisputably overt (completed suicide). Several alternative explanations for the current nil findings are also discussed.     

Sequelae of Aggression in Acutely Suicidal Adolescents

The consequences of aggression on problem course and suicide risk were examined in 270 acutely suicidal adolescents (ages 12-17 years; 184 girls). Participants were assessed during psychiatric hospitalization (T1), 6-months post-hospitalization (T2), and 15 or more months post-hospitalization (T3). Study variables included self- and parent-reported aggression; self-reported internalizing symptoms, suicidal ideation, suicide attempt, and adverse events; and clinician-rated suicidal behavior. Aggression was not directly related to suicide attempt concurrently or prospectively. However, among more aggressive youth, internalizing symptoms were more predictive of T3 suicide attempt than among less aggressive youth. T1 aggression predicted aggressive incidents and the likelihood of incarceration prior to T3. Two-level hierarchical linear modeling indicated that self-reported aggression and internalizing problems were linked in terms of severity and rates of decline over time. Overall, parent-reported aggression was negatively associated with suicidal ideation. Findings highlight (a) the continuity and consequences of aggression, (b) a possible role of aggression in worsening suicide risk factors and potentiating suicide attempt, and (c) the importance of ongoing research on subtypes of suicidal adolescents.     

Hopelessness and Lack of Connectedness to Others as Risk Factors for Suicidal Behavior Across the Lifespan: Implications for Cognitive-Behavioral Treatment

The rates of suicide attempts and death by suicide vary considerably over the lifespan, highlighting the influence of different contextual, risk, and protective factors at different points in development (Daniel & Goldston, 2009). Hopelessness and lack of connectedness to others are two factors that have been associated with increased risk for suicidal thoughts and behaviors across the lifespan. The primary purposes of this paper are to describe how hopelessness and lack of connectedness to others may contribute to risk for suicidal behaviors, and to outline empirically supported cognitive-behavioral interventions for these difficulties at three developmental periods during which suicidal behavior is prevalent: (a) adolescence and young adulthood, (b) middle adulthood, and (c) older adulthood. This paper is not intended as an exhaustive review, but rather an overview of selected developmental issues related to hopelessness and lack of connectedness to others as risk factors for suicidal behavior. Special emphasis is given to clinical implications for cognitive-behavioral interventions, which are illustrated through case conceptualizations and examples at each developmental period.     

Dissociation,Physical Pain,and Suicide: A Hypothesis

The hypothesis of this paper states that at least some suicidal individuals are characterized by a disposition toward dissociation manifested in relative insensitivity to physical pain and indifference to their bodies. Three main topics are discussed: dissociation and suicide, psychological aspects of pain, and pain and suicide. Various theoretical and experimental studies suggest that certain stress conditions lead to the development of dissociative tendencies, and that once these tendencies are established, they become an integral part of suicidal behavior. Psychological variables that affect pain tolerance are presented and they include perception, motivation, emotions, and behavioral and cognitive strategies of pain control. These can increase tolerance of pain in suicidal individuals, making the suicidal act possible. The specific relationships of pain and suicide are then introduced through an examination of pain analgesia in the phenomenon of self-harm. The integration of the material suggests that early and continuous stress lead to the simultaneous development of dissociative tendencies (including indifference to the body and pain) and heightened vulnerability to stress. These dispositions may facilitate suicidal behavior in the face of mounting intolerable stress, helplessness, and hopelessness. Preliminary empirical support for the present hypothesis is cited. This hypothesis shifts the focus of attention from the question of what causes suicide to what facilitates suicide, and in so doing suggests new directions for research and therapy.     

Associations between delinquency and suicidal behaviors in a nationally representative sample of adolescents

Suicide was the second leading cause of death for 14-17 years olds in 2002. Prior studies indicate that suicidal behaviors are especially common among juvenile delinquents, yet this association has not been examined in a national sample. The 2003 Youth Risk Behavior Surveillance System was used to examine associations between suicidal behaviors and delinquency in a nationally representative sample of 14-17 year olds. Results indicated that delinquent adolescents were more likely to have seriously considered suicide (adjusted odds ratio [AOR] = 5.44), made a suicide plan (AOR = 4.90), attempted suicide (AOR = 10.08), and required medical treatment after attempting suicide (AOR = 14.61) compared to their nondelinquent counterparts. Delinquency was significantly related to suicidal behaviors for boys and girls, but the magnitudes of effects were larger for girls. This finding suggests that delinquent youth, particularly delinquent girls, should be targeted in interventions to reduce suicidal behaviors.     

Incidence of suicidal ideation and behavior in the United States, 1994.

Completed suicides reflect only a portion of the impact of suicidal behavior; sublethal behaviors cause morbidity and can signal treatable problems such as depression. There is no national quantification of nonlethal suicidal behaviors. The present study used a random-digit-dialed telephone survey to estimate the 12-month incidence of suicidal ideation, planning, and attempts among U.S. adults. Of 5,238 respondents, 5.6% (representing about 10.5 million persons) reported suicidal ideation, 2.7% (about 2.7 million) made a specific suicide plan, and 0.7% (about 700,000) made a suicide attempt (estimate = 1.1 million attempts). Hence, suicidal behaviors are not uncommon and occur along a continuum ranging from ideation to completed suicides. Preventing nonlethal precursor behaviors may prevent deaths.     

Nonlinear change processes and the emergence of suicidal behavior: A conceptual model based on the fluid vulnerability theory of suicide

Although ideation-to-action theories of suicide aim to explain the emergence of suicidal behaviors, researchers have primarily focused on the content of underlying mechanisms (i.e., who dies by suicide). Much less attention has focused on the temporal dynamics of suicide risk (i.e., when suicide occurs). The fluid vulnerability theory conceptualizes suicide as an inherently dynamic construct that follows a nonlinear time course. Newer research implicates the existence of multiple nonlinear change processes among suicidal individuals, some of which appear to be associated with the emergence of suicidal behavior. The cusp catastrophe model provides a useful model for conceptualizing these change processes and provides a foundation for explaining a number of poorly understood phenomena including sudden emergence of suicidal behavior without prior suicidal planning. The implications of temporal dynamics for suicide-focused theory, practice, and research are discussed.     

Suicidal behavior among youth with severe emotional disturbance

The purpose of this study was to replicate an investigation of risk behaviors associated with suicidal behavior in public high school students, in a population of high school age youth with severe emotional disturbance (SED). Subjects for the study were clients of the South Carolina Continuum of Care (COC) (N=83). Information on suicidal thoughts and acts, aggressive behaviors, substance use and physical recklessness was gathered using a modified version of the self-report National Youth Risk Behavior Survey. Four percent of the youth reported seriously considering suicide, 8% reported planning how they would attempt suicide, 10% reported actually attempting suicide at least once, and 6% reported attempts requiring medical treatment Of the 13 youth who reported attempting suicide, four (31%) did not report planning an attempt. All suicidal behaviors except thoughts occurred more in girls than boys with SED. Alcohol and illicit drug use were associated with suicidal behavior, with larger odds ratios for attempts than for thoughts/plans. Youth with SED who use alcohol and illicit substances are particularly at risk of suicidal behavior. A high index of suspicion is appropriate when evaluating suicidal risk in girls with SED, especially in the presence of known alcohol or substance use.Continuum of Care for Emotionally Disturbed Children Division, S. C. Office of the Governor.     

Revisiting the association of aggression and suicidal behavior in schizophrenic inpatients

Our study investigated the association of aggression and suicidal behavior in schizophrenic inpatients. Eight thousand nine hundred one admissions for schizophrenia (1998-2007) to a psychiatric university hospital were included. Schizophrenic suicides (n = 7)/suicide attempters (n = 40) were compared to suicides (n = 30)/suicide attempters (n = 186) with other diagnoses and to schizophrenic non-attempters regarding aggression. Logistic regression analysis was performed to explore risk factors for attempted suicide. Schizophrenic suicides/suicide attempters did not differ from other suicides/suicide attempters or from schizophrenic non-attempters with regard to aggression. Risk of inpatient suicide attempt was increased for patients with attempted suicide at admission, high school graduation, and disorganized subtype. Aggression could not be found to be a predictor of attempted suicide. Aggression seems to have a minor role for suicidal behavior in schizophrenia.     

Suicidal Behavior in the Western Pacific Region: Characteristics and Trends

Current knowledge of suicidal behavior in the Western Pacific region is relatively limited when compared to other areas of the world. This area is characterized by a wide diversity of social, economic, and cultural aspects that do not permit any homogenous reading of suicide phenomena. Data from countries of the region included in this article suggest the existence of important differences among nations in terms of gender, age, and methods of suicide, as well role of mental illness. In addition, the Western Pacific region appears to be affected by higher rates of suicide than other areas in the world, with signs of progressive worsening in recent years and worrying predictions for the next two decades. The Suicide Trends in At‐Risk Territories (START) Study, initiated by the World Health Organization Regional Office in Manila, seeks to research the incidence of both fatal and nonfatal suicidal behavior in countries of the region and to implement interventions for suicide attempters. This ambitious project is expected to standardize data collection procedures and improve the knowledge cultural factors in suicide.