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.     

云南省大学生自杀行为及相关因素分析

采用SCL-90、青少年生活事件量表、应对方式量表、社会支持评定量表和自编的外显行为量表对云南省3313名大学生进行了测查,并探讨了包括自杀意念及自杀企图在内的自杀行为状况及其影响因素。结果表明:(1)427(13.2%)名大学生有自杀意念,卡方检验显示女生人数显著多于男生;154(4.7%)名大学生有过自杀企图,男女生人数没有显著差异;(2)自杀意念和自杀企图在人口统计学变量上有显著差异:在自杀意念上,女生、独生子女、文科生、来自城市的学生和不完整家庭的学生、月支出少于100元的学生得分显著高于与之对应的大学生;而在自杀企图上,只有来自城市的学生和不完整家庭的学生、月支出少于100元的学生得分显著高于与之对应的大学生;(3)大学生自杀意念和自杀企图与心理症状、生活事件、情感中心应对呈显著的正相关,与问题中心应对、社会支持呈显著的负相关;(4)在结构模型中,社会支持在心理症状和自杀行为中起到显著的调节作用,情感中心应对在生活事件、社会支持、社会支持对心理症状的调节作用中起显著的中介作用,而问题中心应对在生活事件、社会支持、社会支持对事件的调节作用中起显著的中介作用。     

The Relationship Between Nonsuicidal Self‐Injury and Suicidal Ideation

This correlational study was conducted with 403 undergraduate college students from 2 universities. The authors used path analysis and bootstrap regression to analyze the relationships between variables. Locus of control and family connectedness related to current nonsuicidal self‐injury (NSSI) engagement. However, when entered into the same regression, the variables current NSSI engagement and current NSSI number of methods used mediated all other relationships with suicidal ideation. Implications to current theories and clinical practice are provided.     

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.     

Interoceptive Abnormalities and Suicidality: A Systematic Review

Dysfunction of interoception (i.e., difficulties sensing the physiological state of one's own body) is increasingly linked to different mental health disorders and suicidal outcomes. The aim of this study was to systematically review the literature on the association between suicidality and interoception, as well as identify potential confounders and mediators of the relationship. We conducted a systematic review of four databases, allowing for critical examination of the role of different measures of interoception (accuracy, sensibility, awareness, cognitive/emotional evaluation) across the suicide continuum (ideation, plans, attempts, deaths). The search strategy identified 22 studies (14,988 participants). Preliminary but limited evidence was found for impaired interoceptive accuracy among those reporting suicide attempt histories. We found evidence of interoceptive sensibility disturbances across the suicide continuum, including experiences of not trusting one’s own body sensations and impaired abilities to sustain and control attention to such sensations. Consistent evidence was also reported for disturbances related to cognitive and emotional evaluations of interoceptive sensations. The latter was particularly pronounced for those reporting suicide attempts, relative to those reporting suicidal thinking or planning alone. Overall, this review’s results suggest that interoceptive abnormalities are potentially important indicators of risk for suicidal thinking, intentions, and behaviors. However, due to the inconsistent adjustment for variables of interest, and cross-sectional designs, it is unclear whether interoceptive changes and disturbances have a direct role, or whether the association is explained and mediated by key third variables (e.g. depression, disordered eating, emotional dysregulation). We discuss the implications with respect to suicidal risk and therapeutic interventions.     

The Relative Contribution of Diagnostic and Psychosocial Variables to Severity of Suicidal Ideation

The present study examined the relative contribution of diagnostic and psychosocial factors to the prediction of severity of suicidal ideation in a sample of 78 college students. Using hierarchical regression analyses to control for each set of factors, psychosocial variables were found to consistently predict level of suicidal ideation. In contrast, diagnostic variables including diagnosis of substance abuse and composite scores for depression and anxiety were unrelated to level of suicidality. An examination of individual diagnoses revealed no predictable relationships with severity of suicidality in this population. The results were discussed from several methodological viewpoints.     

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.     

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.     

Cross‐national comparisons of attitudes towards suicide and suicidal persons in university students from 12 countries

This paper reports the results of a comparative investigation of attitudes to suicide and suicidal persons in 5,572 university students from 12 countries. Participants filled out two scales measuring attitudes towards suicide and suicidal persons, a measure of psychological distress together with the questions about suicidal behavior. Results showed that the highest suicide acceptance scores were observed in Austrian, UK, Japanese and Saudi Arabian samples and the lowest scores were noted in Tunisian, Turkish, Iranian and Palestinian samples. While the highest social acceptance scores for a suicidal friend were noted in Turkish, US, Italian and Tunisian samples, the lowest scores were seen in Japanese, Saudi Arabian, Palestinian and Jordanian samples. Compared to participants with a suicidal past, those who were never suicidal displayed more internal barriers against suicidal behavior. Men were more accepting of suicide than women but women were more willing to help an imagined suicidal peer. Participants with accepting attitudes towards suicide but rejecting attitudes towards suicidal persons reported more suicidal behavior and psychological distress, and were more often from high suicide rate countries and samples than their counterparts. They are considered to be caught in a fatal trap in which most predominant feelings of suicidality such as hopelessness or helplessness are likely to occur. We conclude that in some societies such as Japan and Saudi Arabia it might be difficult for suicidal individuals to activate and make use of social support systems.     

The prevalence of suicidal ideation and suicide attempt in patients with rheumatic diseases: a systematic review and meta-analysis

A number of studies have reported the suicidal ideation (SI) or suicide attempts (SA) of patients with rheumatic diseases. However, the estimated prevalence of those disorders varies substantially between studies. This systematic review aimed to describe the prevalence of SI and SA in rheumatic diseases. Literature search was done using Web of Science, Embase, the Cochrane database library, PubMed and CNKI database through June 2017. Studies were screened according to inclusion and exclusion criteria and the qualities of included studies were evaluated. The data was analyzed using STATA version 12.0. A random-effect meta-analysis was conducted on all eligible data. A total of 17 identified studies matched the inclusion criteria, involving 5174 participants with systemic lupus erythematosus (SLE), osteoarthritis (OA), rheumatoid arthritis (RA) and fibromyalgia (FM). Meta-analysis showed that rheumatic diseases patients have high prevalence of SI (26%, 95% CI: 19%-32%, I²=96.2%) and SA (12%, 95% CI: 3%-21%, I²=96.6%). We also found the prevalence of SI and SA in females may be higher than in males. All of these indicated that rheumatologists should screen for SI and SA in their patients. Early appropriate intervention is therefore essential to promote the patients’ good mental health.     

Forgiveness as a moderator of the association between anger expression and suicidal behaviour

Anger is often associated with poor physical and mental health, including suicidal behaviour. Anger expression is typically conceptualised as inward or outward-directed, with each mode of expression having potentially different aetiologies and health manifestations. Individual characteristics such as religion or spirituality may buffer against the effects of anger. One such characteristic, forgiveness, is the voluntary process of changing ones’ beliefs, behaviours, and emotions towards a transgressor from negative to positive. We examined forgiveness of self, forgiveness of others and feeling forgiven by God as moderators of the relationship between anger expression and suicidal behaviours in a sample of 372 ethnically diverse college students. In independent and full models, we found that forgiveness of self was a significant moderator of the association between inward and outward anger and suicidal behaviour. Interventions targeting anger via the promotion of forgiveness may be useful in the prevention of suicide ideation and attempts.     

Integrating the Interpersonal Psychological Theory of Suicide Into the Depression/Suicidal Ideation Relationship: A Short-Term Prospective Study

We examined the hypothesis that depressive symptoms are associated with increased beliefs about perceived burdensomeness and thwarted belongingness identified in the interpersonal psychological theory of suicide and that these beliefs are associated with changes in suicidal ideation. Participants with clinical levels of depressive symptoms (n = 299) were selected from a larger group (n = 508) and completed measures of depressive symptoms, perceived burdensomeness and thwarted belongingness, and suicidal ideation twice over a period of 2 months. Results of a structural equation model found that depressive symptoms were associated with increases in burdensomeness and lack of belonging, which were associated with suicidal ideation. Moreover, this hypothesized integrated model demonstrated a significantly better fit than an alternative model that assumed burdensomeness and lack of belonging were associated with changes in depressive symptoms, which were associated with suicidal ideation. Our findings suggest that the well-established relationship between depressive symptoms and suicidal ideation is associated with changes in beliefs that one is a burden on others and lacks belonging. More generally, these results suggest that it may be fruitful to integrate theories of suicide risk to form a comprehensive model that can inform future research and clinical interventions.     

Introduction to the Special Issue

The authors introduce the special issue of the Journal of Counseling & Development on “Integrating the Multicultural and Social Justice Counseling Competencies Into Practice, Research, and Advocacy.” They first discuss the rationale and importance of the special issue, as well as the transformative opportunities that the Multicultural and Social Justice Counseling Competencies (MSJCC; Ratts, Singh, Nassar-McMillan, Butler, & McCullough, 2015) have to influence counseling and the broader helping professions. Then they provide an overview the special issue articles and their respective contributions. They conclude by explicating the challenges and opportunities in integrating and implementing the MSJCC into counseling practice, research, and advocacy.