A Transdiagnostic Multilevel Examination of Interoceptive Processing in Individuals With a Remote History of Suicidal Behavior

A developing area of research suggests that there may be a relationship between interoception and suicidal behavior. For example, it was recently reported that individuals who made a suicide attempt within the previous 5 years exhibit behavioral and neural abnormalities across multiple domains of interoception relative to nonattempters. This included increased tolerance for aversive sensations of pain and dyspnea, reduced heartbeat-perception accuracy, and blunted insula activity during attention to cardiac sensations. However, the degree to which interoceptive deficits persist following a suicidal attempt is unknown. In the current study, we examined differences between individuals with a remote history of suicide attempts (greater than 5 years ago; N = 56) versus those with no history of attempts (N = 240). We found that remote suicide attempters demonstrated greater pain tolerance and lower ratings of stress during a cold-pressor challenge and lower ratings of suffocation during a breath-hold challenge, as compared to nonattempters. In contrast, there were no group differences in breath-hold duration, interoceptive accuracy on a heartbeat-tapping task, or insula activation during cardiac attention. An exploratory resting-state functional connectivity analysis of individuals with suicide attempts in the past 5 years (N = 23), individuals with more remote histories of suicide attempts (N = 39), and nonattempters (N = 232) revealed preliminary and subtle evidence of differences in insula connectivity with areas of the temporal cortex in remote suicide attempters. Taken together, these findings suggest that blunted affective responses to aversive interoceptive sensations is an enduring characteristic of suicide attempters, even when assessed many years after a suicide attempt, whereas differences in the experience of nonaversive interoceptive sensations may be less persistent.     

Interoception,Pain Tolerance,and Self-Injurious Behaviors: A Multidimensional Assessment

Impairments in interoception have been linked to self-injurious behaviors, and capability for suicide may account for this relationship. However, past studies have relied primarily on self-report and unidimensional measures. The present study aimed to replicate and extend previous findings by examining the relationship between interoceptive dysfunction, pain tolerance, and self-injurious behaviors using a multidimensional and multi-method approach. A sample of 245 undergraduate students (M_age = 19.27 years, SD = 2.81; 73.7% female, 72.% White/European American), who reported lifetime suicidal ideation on a screening survey completed a battery of self-report measures, four counterbalanced pain tolerance tasks, and a clinical interview assessing their self-injurious behaviors. A tendency to stay attuned to bodily sensations was significantly related to decreased pain tolerance. Only trust in one’s body was significantly related to decreased presence of lifetime suicide attempts. No other facets of interoception or pain tolerance were significantly associated with self-injurious behaviors. Overall, these findings contrast with previous findings that capability for suicide may account for relations between interoceptive dysfunction and self-injurious behaviors. Nonetheless, the results of this study provide important information on the factor structure of interoceptive dysfunction and pain tolerance, and highlight the importance of careful selection of measures and operationalization of key constructs, particularly interoceptive dysfunction and pain tolerance.     

Introduction to the Special Issue on Interoception and Suicidality

Empirically informed theories of suicide highlight the importance of identifying factors that lead from suicide ideation to suicidal behavior. Interoceptive dysfunction may be one such differentiating factor. Interoceptive dysfunction refers to a disconnection from the internal sensations of the body, which can cause difficulty in truly understanding and knowing one’s own body. Specifically, interoceptive dysfunction may lead to such disconnection from the self that the body comes to be seen as “other” and potentially even “nonhuman.” A burgeoning body of research supports these theoretical links and also highlights the need for methodologically rigorous studies that employ careful measurement of these constructs. Thus, this special section is devoted to articles that advance the understanding of the relationship between interoception and suicidality. A more nuanced understanding of the relationship between interoceptive dysfunction and suicidality is critical for improving suicide prevention and treatment efforts.     

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.     

Interoceptive sensitivity predicts sensitivity to the emotions of others

Some theories of emotion emphasise a close relationship between interoception and subjective experiences of emotion. In this study, we used facial expressions to examine whether interoceptive sensibility modulated emotional experience in a social context. Interoceptive sensibility was measured using the heartbeat detection task. To estimate individual emotional sensitivity, we made morphed photos that ranged between a neutral and an emotional facial expression (i.e., anger, sadness, disgust and happy). Recognition rates of particular emotions from these photos were calculated and considered as emotional sensitivity thresholds. Our results indicate that participants with accurate interoceptive awareness are sensitive to the emotions of others, especially for expressions of sadness and happy. We also found that false responses to sad faces were closely related with an individual's degree of social anxiety. These results suggest that interoceptive awareness modulates the intensity of the subjective experience of emotion and affects individual traits related to emotion processing.     

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.     

Reconnecting to Internal Sensation and Experiences: A Pilot Feasibility Study of an Online Intervention to Improve Interoception and Reduce Suicidal Ideation

Risk factors that are strongly associated with suicide and are amenable to intervention are in need of discovery. This three-study investigation demonstrates that an intervention designed to improve interoception—one potential suicide risk factor—may reduce suicide-related outcomes. Study 1 included 136 undergraduate participants and found that relative to a control condition, participating in a progressive muscle relaxation exercise was associated with reduced implicit identification with suicide through greater body trust, which is one domain of interoception that is consistently linked to suicide-related outcomes. Study 2 included 97 MTurk participants and found that relative to a control condition, participating in a body functionality writing exercise was associated with greater awareness of the body as a whole. Study 3 was a pilot study of a four-session online intervention designed to increase interoception. Study 3 included a sample of 22 clinical participants who completed pre- and postintervention assessments. Participants rated the intervention as highly acceptable and moderately effective. Moreover, the intervention was associated with improvements in interoception and reductions in suicidal ideation, general psychological symptoms, and disordered-eating symptoms. Overall, these findings indicate that our online interoceptive awareness training is acceptable and may be associated with improvements in clinical outcomes. Randomized controlled trials are needed to explore whether the intervention’s purported mechanism—improved interoception—leads to changes in clinical outcomes.     

Moral Objections and Fear of Hell: An Important Barrier to Suicidality

This review explores the literature to test the hypothesis that ‘moral objections to suicide (MOS), especially the conviction of going to hell after committing suicide, exert a restraining effect on suicide and suicidality.’ Medline and PsycInfo were searched using all relevant search terms; all relevant articles were selected, rated and reviewed. Fifteen cross-sectional studies were available on this topic, and raise sufficient evidence to confirm a restraining effect of MOS, and sparse data on fear of hell. MOS seem to counteract especially the development of suicidal intent and attempts, and possibly the lethality of suicidal attempts. A differential pattern of influence of MOS on the suicidal continuum is suggested.     

Evaluating panic-specific factors in the relationship between suicide and panic disorder

Work during the past decade has suggested an association between panic disorder and suicide (i.e., suicidal ideation and suicide attempts) that cannot simply be accounted for by co-occurring depression symptoms. To clarify the linkage between panic disorder and suicide, the association between panic-specific clinical and cognitive variables and suicide indicators were evaluated in patients with panic disorder (N=146). Analyses predicting the presence of suicidal ideation (positive, negative) after covarying the effects of a current mood disorder diagnosis and depression symptoms indicated a number of significant predictors including: (1) overall anxiety symptoms; (2) level of anticipatory anxiety; (3) avoidance of bodily sensations; (4) attentional vigilance toward bodily perturbations; and (5) phrenophobia (i.e., fear of cognitive incapacitation). Anxiety-specific variables did not account for unique variance in predicting prior history of suicide attempts.     

对话心智与身体：具身认知的内感受研究转向

具身认知观念试图强调心智是根植于身体的,身体经验会对认知过程产生重要影响。但对于心智与身体的对话是如何进行的？身体通过何种渠道如何影响心智？等问题困扰着具身认知的支持者。传统的具身认知研究遭遇可重复性危机,身体状态改变影响高级认知的结论受到质疑。近年来,越来越多的证据表明内感受与身体表征、具身情绪以及社会认知等存在着密切的联系,因而内感受很有可能在身体加工和高级认知过程中起着重要的调节作用。     

The Relation Between Child Maltreatment and Adolescent Suicidal Behavior: A Systematic Review and Critical Examination of the Literature

A large body of research suggests that child maltreatment (CM) is associated with adolescent suicidal ideation and attempts. These studies, however, have not been critically examined and summarized in a manner that allows us to draw firm conclusions and make recommendations for future research and clinical work in this area. In this review, we evaluated all of the research literature to date examining the relationship between CM and adolescent suicidal ideation and attempts. Results generally suggest that childhood sexual abuse, physical abuse, emotional abuse, and neglect are associated with adolescent suicidal ideation and attempts across community, clinical, and high-risk samples, using cross-sectional and longitudinal research designs. In most studies, these associations remain significant when controlling for covariates such as youth demographics, mental health, family, and peer-related variables. When different forms of CM are examined in the same multivariate analysis, most research suggests that each form of CM maintains an independent association with adolescent suicidal ideation and suicide attempts. However, a subset of studies yielded evidence to suggest that sexual abuse and emotional abuse may be relatively more important in explaining suicidal behavior than physical abuse or neglect. Research also suggests an additive effect—each form of CM contributes unique variance to adolescent suicide attempts. We discuss the current limitations of this literature and offer recommendations for future research. We conclude with an overview of the clinical implications of this research, including careful, detailed screening of CM history, past suicidal behavior, and current suicidal ideation, as well as the need for integrated treatment approaches that effectively address both CM and adolescent suicidal ideation and suicide attempts.     

Suicidal behavior in borderline personality disorder: prevalence, risk factors, prediction, and prevention

Suicidal behavior is frequent in patients with borderline personality disorder (BPD); at least three-quarters of these patients attempt suicide and approximately 10% eventually complete suicide. Borderline patients at greatest risk for suicidal behavior include those with prior attempts, comorbid major depressive disorder, or a substance use disorder. Comorbidity with major depression serves to increase both the number and seriousness of the suicide attempts. Hopelessness and impulsivity independently increase the risk of suicidal behavior, as does a turbulent early life and the presence of antisocial traits. In summary, because BPD is frequently complicated by suicidal behavior, clinicians must avoid the mistake of thinking that a pattern of repeated attempts indicates little desire to die. Clinicians have an important role in preventing suicide attempts and completed suicides by understanding the risk factors.     

Suicide Crisis Syndrome: A review of supporting evidence for a new suicide‐specific diagnosis

Suicide is a major public health problem, and suicide rates are still on the rise. Current strategies for identifying individuals at risk for suicide, such as the use of a patient's self‐reported suicidal ideation or evidence of past suicide attempts, have not been sufficient in reducing suicide rates. Recently, research groups have been focused on determining the acute mental state preceding a suicide attempt. The development of an acute suicidal diagnosis, the Suicide Crisis Syndrome (SCS), is aimed at capturing this state to better treat individuals. The SCS has five main evidence‐based components—entrapment, affective disturbance, loss of cognitive control, hyperarousal, and social withdrawal. The SCS may provide clinicians with the ability to identify individuals who are experiencing an acute pre‐suicidal mental state, regardless of their self‐reported suicidal ideation. Future research leading to the incorporation of this diagnosis into clinical practice could improve the quality of care and reduce the personal, societal, and legal burden of suicide.     

Suicidal Ideation and Eating Disorder Symptoms in Adolescents: The Role of Interoceptive Deficits

Eating disorder symptoms and suicidal ideation are relatively common, and often begin to emerge in adolescence. Interoceptive deficits, or the inability to perceive and accurately identify the physiological condition of the body, is an established risk factor for both eating disorders and suicidal thoughts and behaviors. Despite this, longitudinal research examining the temporal dynamics between these variables is scarce, especially within adolescent samples. Using a three-wave longitudinal design, the present study tested bidirectional relationships between interoceptive deficits, eating disorder symptoms, and suicidal ideation to examine whether interoceptive deficits predicted eating disorder symptoms and suicidal ideation over the course of a year among a sample of adolescents. Participants were 436 community adolescents recruited from local middle- and high-schools. Data were collected at baseline, 6-month follow-up, and 12-month follow-up. Study measures assessed current suicidal ideation, eating disorder symptom severity, and interoceptive deficits. Autoregressive cross-lagged modeling was conducted in MPlus. We found baseline eating disorder symptoms significantly predicted suicidal ideation at 6-month follow-up when controlling for baseline suicidal ideation. Baseline interoceptive deficits significantly predicted eating disorder symptoms 6-months later, while 6-month follow-up interoceptive deficits significantly predicted 12-month follow-up suicidal ideation. Our findings highlight the need for early and regular assessment of suicidal ideation and eating disorder symptoms in adolescents. Given that interoceptive deficits was a shared risk factor for both conditions within this sample, these results underscore the need for targeted interventions aimed at improving interoception.     

Suicidality in adolescence: review and legal considerations

Adolescence is a unique developmental stage in which suicidality first emerges as a public health problem. The increasing trend of teenage suicide since the 1950s has only relented in the past ten years. The risk factors for adolescent suicide, suicidal ideation, and suicide attempts and an approach to assessing the suicidal adolescent for risk of future self-harm are reviewed. Treatment consists of ensuring safety and then treating the underlying psychiatric, psychological, and interpersonal disturbances. Issues of consent, confidentiality, and malpractice actions are addressed.     

Individual differences in emotional processing and autobiographical memory: interoceptive awareness and alexithymia in the fading affect bias

The capacity to perceive internal bodily states is linked to emotional awareness and effective emotional regulation. We explore individual differences in emotional awareness in relation to the fading affect bias (FAB), which refers to the greater dwindling of unpleasant compared to pleasant emotions in autobiographical memory. We consider interoceptive awareness and alexithymia in relation to the FAB, and private event rehearsal as a mediating process. With increasing interoceptive awareness, there was an enhanced FAB, but with increasing alexithymia, there was a decreased FAB. Further, the effects of interoceptive awareness were partially mediated by private rehearsal of pleasant events. We provide novel evidence that capacity for emotional awareness and thus effective processing is an important factor predictive of the FAB. Moreover, our results imply an important role for maintaining positive affect in the FAB. Our findings offer new insights into the effects of interoception and alexithymia on autobiographical memory, and support concepts of the FAB emerging as a result of adaptive emotional regulation processes.     

Interoceptive Deficits,Nonsuicidal Self‐Injury,and Suicide Attempts Among Women with Eating Disorders

People with eating disorders (ED s) have an elevated risk for both nonsuicidal self‐injury (NSSI ) and suicide compared to the general population. This study tests two theoretically derived models examining interoceptive deficits as a risk factor for NSSI , and examining interoceptive deficits, NSSI , fearlessness about death, and pain tolerance as risk factors for suicide. Ninety‐six adult, treatment‐seeking women with ED s completed self‐report questionnaires at a single time point. Interoceptive deficits were significantly associated with NSSI , and NSSI was in turn associated with both pain tolerance and fearlessness about death. Further, pain tolerance was in turn associated with past suicide attempts, although fearlessness about death was not associated with suicide attempts. Interoceptive deficits had a direct association with fearlessness about death but not pain tolerance. Results regarding the relation between interoceptive deficits and suicide attempts were mixed, yet overall suggest that interoceptive deficits are related to suicide attempts largely indirectly, through the effects of mediating variables such as NSSI , fearlessness about death, and pain tolerance. Results suggest that interoceptive deficits and pain tolerance merit further investigation as potential risk factors for fatal and nonfatal self‐harm among individuals with ED s.     

More of myself: Manipulating interoceptive awareness by heightened attention to bodily and narrative aspects of the self

Psychology distinguishes between a bodily and a narrative self. Within neuroscience, models of the bodily self are based on exteroceptive sensorimotor processes or on the integration of interoceptive sensations. Recent research has revealed interactions between interoceptive and exteroceptive processing of self-related information, for example that mirror self-observation can improve interoceptive awareness. Using heartbeat perception, we measured the effect on interoceptive awareness of two experimental manipulations, designed to heighten attention to bodily and narrative aspects of the self. Participants gazed at a photograph of their own face or at self-relevant words. In both experimental conditions interoceptive awareness was significantly increased, compared to baseline. Results show that attention to narrative aspects of self, previously regarded as relying on higher-order processes, has an effect similar to self-face stimuli in improving interoceptive awareness. Our findings extend the previously observed interaction between the bodily self and interoception to more abstract amodal representations of the self.     

Emotional antecedents and consequences of deliberate self-harm and suicide attempts

Emotional experiences immediately prior to (emotional antecedents) and following (emotional consequences) deliberate self-harm and suicide attempts in female inmates (N = 63) were examined. Anger was the antecedent emotion reported by the largest proportion of individuals who had engaged in deliberate self-harm (45.16%), suicide attempts (40.9%), and ambivalent suicide attempts (30%). Relief and other positive emotional shifts were more common in deliberate self-harm (41.94%) (involving no intent to die) than in suicide attempts or ambivalent suicide attempts, particularly for persons with borderline personality disorder. These findings underscore the utility of discriminating between deliberate self-harm and suicidal behavior and highlight the potential role of anger in triggering such behaviors.     

Cognitive style and suicidal behaviour: implications for therapeutic intervention, research lacunae and priorities

Cognitive style is a well-established theoretical construct but there is considerable ambiguity in the way it has been used and uncertainty regarding the nature of its role in suicide. There is no evidence that specific cognitive dispositions prime people for suicide but there are indications that suicide is associated with a constriction in cognitive style. This constriction leads to decrements in problem-solving and information processing that can be addressed in therapeutic contexts. To help a suicidal person become a better problem-solver is not a trivial task but the evidence suggests that enriching cognitive styles through the development of thinking skills is possible when the therapy session is construed as a learning collaboration.