Illicit Drug Use,Cognitive Distortions,and Suicidal Ideation Among Homeless Youth: Results From a Randomized Controlled Trial

Illicit drug use and cognitive distortions confer significant risks to youth suicidal thoughts and behaviors. However, there has been limited evidence regarding the efficacy of suicide prevention interventions with homeless youth, especially studies testing whether such interventions can reduce the risk for suicidal ideation associated with illicit drug use. Suicidal homeless youth (N = 150) between the ages of 18 to 24 years were recruited from a drop-in center. Youth were randomly assigned to Cognitive Therapy for Suicide Prevention (CTSP) + Treatment as Usual (TAU) or TAU alone. Youth reported their illicit drug use, cognitive distortions, and suicidal ideation 4 times over 9 months. A multiple-group multilevel structural equation model showed that higher illicit drug use at baseline predicted a slower reduction in cognitive distortions and suicidal ideation in the TAU group. These associations were not found in the CTSP + TAU group, suggesting an interruption of such risk from illicit drug use. Findings suggest that CTSP can reduce the risk of illicit drug use as a treatment barrier towards cognitive distortions and suicidal ideation among homeless youth, with implications to improve treatment efforts and to reduce premature mortality in a vulnerable population.     

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.     

Differences in emotion modulation using cognitive reappraisal in individuals with and without suicidal ideation: An ERP study

Difficulties in emotion regulation have been associated with increased suicidal thoughts and behaviours. The majority of studies have examined self-reported use of emotion regulation strategies. In contrast, the current study focused on a direct measure of individuals’ ability to use a specific emotion regulation strategy, cognitive reappraisal, using the late positive potential (LPP), an event-related potential component that reflects attention to emotional stimuli. Specifically, the cognitive reappraisal ability of 33 undergraduate students was assessed via an image-viewing task during which the participants had to passively view, increase or reduce their emotions in response to looking at neutral, positive or dysphoric images. We found that participants with a history of suicidal ideation (SI) had significantly higher LPP when asked to reduce negative emotion in response to dysphoric images, compared to individuals with no history of SI. These findings suggest that difficulties with using cognitive reappraisal, specifically to decrease negative affect, might be linked to suicide risk.     

Childhood stress leads to later suicidality via its effect on cognitive functioning

The present study examined the etiology of suicidal behavior from cognitive and developmental perspectives in a sample of 181 suicidal and nonsuicidal college students. We hypothesized that cognitive functioning would serve as a mediator between early life events and suicidal behavior. The present study examined child maltreatment, family instability, and poor general family environment as early negative life events, and examined self-esteem, locus of control, hopelessness, and problem-solving deficits as cognitive factors. In addition, individuals' perceived social support before age 18 and current social support and life stress were also examined in relation to the preceding variables. A series of structural equation analyses indicated that early negative life events have a mild impact on suicidal behavior, but a stronger impact on cognitive deficits, which in turn have a strong impact on suicidal behavior.     

Writing characteristics of suicidal people on the Internet: a psychological investigation of emerging social environments

Three studies were carried out to investigate the writings of suicidal people on the Internet, hypothesizing consistent findings to equivalent research of offline writing. In Study 1, suicidal persons' (n = 34) attributions as the cause of their condition, as expressed in their free online writing, were compared to those of emotionally distressed, nonsuicidal (n = 16) and to nondistressed (n = 15) individuals. Results showed that suicidal persons have significantly more stable and global attributions than do the other groups. In Study 2, expressions of self-focus in online written messages were compared among suicidal, two levels of nonsuicidal but distressed, and nondistressed individuals (200 messages in each group). With the use of various expressions of self-focus, findings showed that suicidal people were distinctively self-focused in their writing, unlike their counterparts. In Study 3, psychologically relevant themes in the online writing of suicidal (n = 39) and highly distressed, nonsuicidal persons (n = 24) were compared. Results revealed that the former expressed significantly more unbearable psychological pain and cognitive constriction than did the latter. The findings of the three studies are consistent with those found in examinations of offline writing. The research has important implications for the use of online environments for psychological research and means for assessment, as well as for understanding suicidality.     

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.     

Neuropsychological performance and suicidal behavior in adult psychiatric inpatients.

Although various studies have shown that suicidal persons exhibit greater cognitive deficiencies than both normals and other psychiatric patients, researchers as yet have been unable to account for the source(s) of the differences. Some of these differences (e.g., cognitive rigidity and impaired problem solving) hint of possible organic involvement. This study explored the relationship of neuropsychological functioning to suicidal behavior by comparing 20 suicidal and 27 nonsuicidal psychiatric inpatients on several tests of neuropsychological functioning. Although results showed no significant differences between the two groups on most measures, both groups showed evidence of notably high levels of cortical dysfunction relative to test norms. Thirty-five percent of suicidal patients and 44% of nonsuicidal patients scored in the impaired range. Implications of this high frequency of impairment for the treatment of suicidal and nonsuicidal psychiatric patients are discussed.     

A cognitive model of suicidal behavior: Theory and treatment

With some prominent exceptions, much of the research designed to elucidate the nature, prevalence, and correlates of suicidal behavior has been conducted from an atheoretical perspective. Conversely, psychological theories to explain suicidal behavior are largely untested by rigorous experimental designs. We propose a cognitive model of suicidal behavior that is grounded in the empirical literature on cognitive and behavioral correlates of and risk factors for suicidal behavior. In addition, we demonstrate the manner in which the theoretical components are targeted in cognitive therapy for suicidal patients. We highlight aspects of the model with less empirical support, and we propose ways those constructs can be tested in future research.     

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.     

Perfectionism, cognitive bias, and hopelessness as prospective predictors of suicidal ideation

Perfectionism, negative cognitive bias, and hopelessness were assessed among people hospitalized for depression (N = 121). Hopelessness and suicidal ideation were assessed 6 months after discharge. Path analyses indicated that higher perfectionism as an inpatient was directly associated with higher suicidal ideation 6 months later. Cognitive bias, in contrast, led to greater hopelessness 6 months later, which in turn led to higher concurrent suicidal ideation. Alternative models examined whether hopelessness partially or fully mediated the effect of perfectionism, whether hopelessness partially mediated the effect of cognitive bias, and whether inpatient depression and suicidal ideation severity explained the observed relationships. These alternative models were not supported. Perfectionism and negative cognitive bias both uniquely contributed to the prospective prediction of suicidal ideation.     

Body attitudes and body experiences in suicidal adolescents

The relationships between cognitive and affective attitudes toward the body, body experiences (dissociation, insensitivity, and lack of control), and suicidal tendencies were examined as a derivative of the hypothesis that bodily attitudes and experiences may facilitate suicidal acting out. Three groups of adolescents (aged 14-18), including suicidal (made a suicide attempt) and nonsuicidal inpatients and controls, were compared with regard to suicidal tendencies, various body aspects, and depression and anxiety. A series of MANOVAs, discriminant analysis, Pearson correlations, and regressions were employed. The results show that the suicidal group differed from the two nonsuicidal groups in feelings toward the body, body protection, and body dissociation. Some aspects of bodily measures discriminated between suicidal and nonsuicidal subjects. In addition, various bodily measures were associated with and statistically predicted suicidal tendencies. The discussion focuses on the web of associations between body attitudes and experiences and their role in suicidal behavior.     

The influence of cognitive emotion regulation strategies and depression severity on deliberate self-harm

Elaborating on previous studies on emotion regulation and deliberate self-harm (DSH), in the present study we distinguish between strategies of cognitive content (e.g., suicidal cognitions of perceived burdensomeness, helplessness, poor distress tolerance) and cognitive process (e.g., nonacceptance of emotional responses, lack of awareness of emotional responses). Young women who harmed themselves (n = 85) were compared with young women without a history of DSH (n = 93) across a broad range of strategies. Significant group differences were found for all measures, even when depression severity was controlled for. In addition, logistic regression analyses showed that both cognitive content strategies and cognitive process strategies made significant independent contributions to the prediction of group membership. Controlling for depression severity, suicidal cognitions, and nonacceptance of emotional responses independently predicted DSH. The strong association between suicidal cognitions and DSH seems to indicate the important role of these cognitions in recurrent and chronic DSH. The strong association between nonacceptance of emotional responses and DSH underscores the notion that DSH can be a way to avoid emotional problems. These findings are discussed in relation to recent cognitive-behavioral interventions and specific therapeutic techniques to further insight into how these interventions might work.     

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.     

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.     

Associations of Emotional Abuse Types With Suicide Ideation Among Dating Couples

Numerous studies have demonstrated that coercive control is more strongly associated with suicidal ideation than other forms of intimate partner violence. However, a majority of these studies focused on samples of help-seeking women. This study examined whether coercive control remains the form of intimate partner violence most strongly associated with suicidal ideation within a sample of nonclinical dating couples. This cross-sectional, survey study on 104 dating couples examined the associations of coercive control (i.e., dominance/intimidation and restrictive engulfment) with suicidal ideation, while controlling for other forms of emotional abuse (i.e., hostile withdrawal and denigration), physical assault, and depressive symptoms. As expected, dominance/intimidation and depressive symptoms, but not denigration and physical assault, were associated with suicidal ideation. Contrary to our hypothesis, hostile withdrawal, but not restrictive engulfment, was associated with suicidal ideation. This study suggests that dominance/intimidation and hostile withdrawal are forms of emotional abuse that are pertinent to suicidal ideation in nonclinical dating couples.     

Working With the Suicidal Client Who Also Abuses Substances

Substance use disorders and suicidal thoughts and behaviors commonly co-occur in adolescent and adult psychiatric populations and are often functionally interrelated. Although the evidence base for treatment of this population is sparse, integrated cognitive behavioral treatment (CBT) protocols, or those that rely heavily on CBT techniques, hold promise. In this paper, we provide an overview of the evidence-based literature for interventions that target suicidal behavior and substance use disorders with adults and adolescents. We then discuss the manner in which these behaviors may be functionally interrelated and offer a conceptual framework (S-O-R-C) to guide case conceptualization and treatment planning for clients with co-occurring suicidality and substance use disorders. Next, we provide a case example of a client with suicidal behavior and an alcohol use disorder and demonstrate how to apply an integrated CBT treatment protocol to this case. This case example is followed by a more general discussion about the potential advantages of integrated CBT protocols for suicidality and substance use disorders, guidelines for prioritizing treatment targets and skill selection for each individual client, and other important treatment considerations. We conclude with recommendations for future research in this area.     

I'm sick of being me: developmental themes in a suicidal adolescent

Adolescence is a developmental transition period during which there are profound transformations in emotional, cognitive, and behavioral systems. Despite being a time of rapid development and increasing rates of suicidality, limited research has examined possible interrelationships. Through the use of a case study, this paper illustrates the role of developmental factors in a teenage girl's experience becoming and overcoming being suicidal. The processes of cognitive development, identity formation, and autonomy-seeking are discussed within the context of her story.     

Are Reports of Life Event Stress among Suicidal Youth Subject to Cognitive Bias?

Severity of depressive symptoms, hopelessness, and suicidal ideation were examined to determine whether they were significantly associated with the accuracy of suicidal adolescents' ratings of stressful life events. The sample included 130 inpatient adolescents who endorsed suicide‐related behaviors. Stress interviews were administered, and the severity of stressful events was rated separately by adolescents and an independent team. A residualized cognitive bias score was created by regressing adolescents' severity ratings to the independent team's severity ratings of the same events. Depressive symptoms, but not hopelessness or suicidal ideation, were significantly associated with cognitive bias scores. A negative cognitive bias in adolescents' reports of life stress may be present at higher levels of depression relative to minimal levels of depression. Further research on the relations between stress and suicide‐related behaviors is encouraged to include independent ratings of stress severity.     

Distress Tolerance and Anxiety Sensitivity Cognitive Concerns: Testing the Incremental Contributions of Affect Dysregulation Constructs on Suicidal Ideation and Suicide Attempt

Empirical work has suggested relationships among suicide-related outcomes and several constructs related to affect dysregulation, notably anxiety sensitivity (AS) and distress tolerance (DT). However, important questions remain, including the relative contributions of these affect regulation variables as well as the direct contribution of DT on suicidal ideation and prior attempts. The current study sought to better elucidate the nature of these relationships by examining AS, DT, and suicidal ideation and attempt in a clinical sample (N = 192). Consistent with prior work and prediction, findings revealed a significant relationship between the AS cognitive concerns subfactor and suicidal ideation and suicide attempt history after accounting for the effects of DT, gender, and depressive symptoms. In addition, depressive symptoms significantly moderated the relationship between the AS cognitive concerns subfactor and suicidal ideation. After accounting for the influence of AS, analyses revealed that DT approached significance in predicting suicidal ideation, but did not significantly predict suicide attempt history. These results suggest that elevated AS cognitive concerns are particularly relevant to suicide in the context of depressive symptoms. Clinicians may benefit from implementing AS reduction strategies with individuals who endorse elevated suicide risk as well as elevated AS cognitive concerns.     

Association between loneliness and suicidality during middle childhood and adolescence: longitudinal effects and the role of demographic characteristics

The association between loneliness and suicidality has been documented in many studies, but these studies have been limited by cross-sectional designs and the use of adult-only populations. The purpose of the current study was to overcome these limitations by (a) investigating whether the link between loneliness and suicidal thoughts and behaviors occurs cross-sectionally, longitudinally, or both and (b) investigating how the link between loneliness and suicidality might be influenced by different demographic variables, including gender, ethnicity, and socioeconomic status. Logistic regression analyses were used to analyze data from a large sample (N = 937) of youth from the NICHD Study of Early Child Care. Results indicated that loneliness at age 15 years was concurrently associated with both suicidal ideation and suicidal behavior at age 15 years. Loneliness in middle childhood was longitudinally associated with suicidal behaviors at age 15 years, but not with suicidal ideation at age 15 years. None of the demographic characteristics influenced these associations.