L10 Suicidal behaviour Flashcards
Why do we have a lecture on suicidality?
- Lot of people are directly or indirectly affected by suicidal behaviour (relatively rare, but the impact is immense)
- Suicidal thoughts are relatively common
- More knowledge can reduce stigma
- Learn how to understand one of the most complex human behaviors - interesting and challenging to study and understand it from a scientific point of view
- Learn about prevention strategies - can we actually prevent it, if yes, how?
- Improving resilience - therapists are often afraid to ask about it because it’s difficult to predict whether someone will act on such thoughts or not (training professionals is important - part of the new guideline)
What are the myths on suicidality?
- Talking about suicide will increase the chance someone will act on it - not talking about it increases the risk and how we talk about it is important (being judgmental and saying ‘you shouldn’t think that way’ increases the chances as well - as therapists we should learn to dicuss it and further elaborate on it without feeling uncomfortable)
- Most people die by suicide during the Christmas holidays - actually in the spring (Hope that people will get better in spring after depressive period in the winter, but if they don’t they lose the hope and give up)
- Someone thinking of suicide wants to die - most people actually don’t want to die, they just want a different life - without the feelings of entrapement, burdensomness or worthlessness
- The media influence the number of suicides
- Antidepressants increase the risk of suicide
- Artists have an increased risk of suicide
- Suicide runs in the family
- Women mostly talk about suicide, men die more often
- Suicide rate rises during an economic recession
What is the social perspective on why suicidality is a taboo topic?
- James Cook was the first to introduce the term to the Western world. During his visit to Polynesia he came across the word. There it repreented a ban on certain actions or objects. For example, a house was taboo when the king had entered it. The owner was then no longer allowed to live there. → no natural law, it’s a socially determined rule
- As a society we have social norms about suicidality - but this was changing over time
What is the evolutionary perspective on why is suicidality a taboo topic?
- According to the American psychologist Steven Pinker, taboos originate in an innate survival instinct
- Corpses, wounds, and feces cause an instinctive aversion, because they are full of potential pathogens. A bat also seems to me to be a taboo from now on
- Incest would also be an automatic taboo, because our ancestors intuitively felt that this would not lead to healthy offspring - not good for our survival
- Suicidality reminds us of our own vulnerability and we have such an innate feeling against being reminded of it that we do lot of things to avoid it
What is the Terror Management Theory?
- Awareness of Mortality: Humans uniquely recognize that they will eventually die, which can cause existential fear (or “terror”)
- It suggests that as humans we experience enormous fear when we are reminded of our own mortality. We are programmed to survive, reproduce and live as long as possible
- People create and embrace cultural belief systems (such as religion, ideologies, norms, and values) to
provide meaning and order to life. These worldviews offer a sense of symbolic immortality by making individuals feel part of something greater that outlives them - We are so scared that we won’t live forever, that we try to control it → We need to manage the terror within → The idea of life after death is a great management
- The authors of the terror management theory even dare to state that every human action and behavior stems from our fear of death
How does self-esteem serve as a buffer according to the Terror Management Theory?
- Self-esteem is a key psychological mechanism that helps reduce the fear of mortality
- By aligning with the norms and expectations of their cultural worldview, individuals gain a sense of personal value and significance
- Suicidality is against popular opinion that life is precisious and we should cherish it
- It is precisely when people are reminded of death, for example when they walk through a cemetery, that they cling more firmly to the image they have of themselves and to the norms and values of their own culture
- Membership of a culture thus becomes an important weapon against death
How does this theory explain why is suicide a taboo subject and will probably remain so?
- Thinking or talking about suicide is so intense for many that in response they cling more firmly to the culturally dominant idea about suicide, namely that you are not even allowed to think about it
- People who have attempted suicide come into contact with this most directly when they are confronted with emergency room workers who say things like: ‘Do it right next time and don’t bother us again.’ For this group of emergency room workers, who try to save people’s lives every day after an accident, for example, suicide is an incomprehensible and socially unacceptable act.
How did people’s thinking about suicide change from ancient greece to middle ages?
Ancient Greek - suicidal behaviour saves your soul, you have control over your life; saw it a legitimate way to dispose of one’s own body
Middle ages, western countries - suicide became illegal and a sin
How was suicide considered after enlightment and french revolution?
- Suicide slowly but surely began to lose its status as a punishable act
- Someone who died as a result was no longer seen as a sinner, but as a sick person
- However, it took a long time before the ban was actually lifted
- In the Netherlands, suicide was no longer punishable in the 17th century, but in England it took until 1961 and in the United States until 1966
- In several Arab and African countries, suicide is still prohibited
- During Enlightement, David Hume argued that suicide was not inherently immoral and that individuals had the right to control their own lives (but he didn’t put any emphasis on the effect that suicide has on others)
What was Albert Camus’ view on suicide in his book Myth of Sisyphus (1942)?
- ‘There is but one truly serious philosophical problem and that is suicide’ - he’s against suicide
For Camus, suicide arises from a confrontation with the absurd, which he defines as the clash between:
- The human desire for meaning, purpose, and clarity
- The universe’s silent indifference to these desires
What did WHO do in terms of suicide?
WHO tries to gather data, monitor and develop policies about suicide on a global level
What is suicide?
The act of deliberately killing oneself
- how do we determine that it was a suicide? medical doctor needs to determine this (someone hit a tree by accident, someone hang themselves - murder staged like suicide or actually suicide?) - this varries in countries how it’s determined = that’s why the suicide rates are higher/lower in some countries - better registration of suicides or attempts is needed
What is a suicidal attempt?
Any non-fatal suicidal behaviour: intentional self-inflicted poisoning, injury or self-harm, which may or may-not have a fatal intent or outcome
Why are suicide attempts so problematic?
- Social and economic burden
- Impact on the person and associates
- Utility of health services
How should health information systems improve monitoring of suicide, as suggested by WHO?
- death registration through civil registration and vital statistics systems (CRVS), local health and demographic studies and other sources
- cause-of-death data collection through vital registration and verbal autopsy in communities
- regular household health surveys
- complete facility recording and reporting with regular quality control
How can monitoring suicide attempts help?
- Interviews wirh people who survived suicidal attempts helps to understand this behaviour
- Best predictor of future suicidal behavior
- Helps prevention strategies
- Combined with suicidal deaths helps to estimate the case fatality rate of suicidal behavior
What are prevention strategies suggested by WHO?
- limiting access to the means of suicide, such as highly hazardous pesticides and firearms;
- interacting with the media for responsible reporting of suicide
- fostering socio-emotional life skills in adolescents
- early identification, assessment, management and follow-up of anyone who is affected by suicidal behaviours
What are two methods of data collection of suicide attempts?
- Self reports in surveys of community residents (In the Netherlands Nemesis)
- From medical records
What are the methodological challenges with suicide attempts?
- Different survey instruments
- Different sample
- Different language
- Literacy of sample
- Time-frame
- Stigma
- Fluctuations of suicidal behavior over time
Suicidal behaviour
Refers to a range of behaviours that include thinking about suicide (or ideation), planning for suicide, attempting suicide and suicide itself
Key statistics about suicidality
- In 2019, more than 700 000 people die due to suicide every year (in the Netherlands about 1900 per year) - there are more people who die from a heart disease but the impact from suicide is probably bigger (close ones, people who found them, psychologist blaming themselves…)
- 9 people per 100 000; 5 suicides per day in the Netherlads
- For every suicide there are many more people who attempt suicide. A prior suicide attempt is an important risk factor for suicide in the general population.
- Suicide is the fourth leading cause of death among 15-29 year-olds (young adults don’t die as easily that’s why fourth; in adults it’s the second one - traffic accidents first one)
- 77% of global suicides occur in low- and middle-income countries - prevention should be targetted here
- ingestion of pesticide, hanging and firearms are among the most common methods of suicide globally (US- people die from firearms - especially military people; but there are still more people dying from suicide than by gun fire - one of the few countries where suicide rates are actually growing)
Language matters
- suicide often used by researchers and policy makers
- in dutch, zelfmoord in media and debate but people don’t like this because the word murder is there so it has a negative tone and creates even more stigma
- Committed suicide replaced with died by suicide
- Instead of suicide attempters we use people that did a suicide attempt
Why do suicide rates differ across countries?
- Age-standardized because some countries are bigger than others so they give it per 100 000 (they pretend everybody has the same age build up)
- Belgium has higher rate than Netherlands - less availability of health care system, more stigma
- Latin america - less prevalence because problems with data collection - data is just estimated
- picture 1
What are the gender differences in suicide rates?
- picture 2
- 3 times more males die than females - weird because actually females do more suicidal attempts and have more suicidal thoughts - men use more lethal methods - more impulsive, aggressive, use more alcohol
- The male:female ration differs between countris: the ratio in high-income countries is little over 3, tha ratio was lower in low- and middle-income countries
- China: females have more deaths by suicide than males
- females in lower-middle-income countries had the highest suicide rates whereas males in the high-income countries had the highest rate
What were the changes in suicide rates over time?
2000-2019, rates decreased by 36% globally (except for the Americas where the rates increased)
What are the challenges with registration?
- Suicide rates vary between countries from 0.4-44 per 100 000
- of the WHO’s 183 countries, 80 provide good quality
What is the vulnerability paradox?
- Absolute number higher in middle and low income countries - more people live there
- But if age-standardized suicide rates = suicide rates in high income countries is the highest
Why does the vulnerability paradox happen?
- Many reasons and it’s not exactly clear why
- Challenges with registration
- Individual countries - if things go wrong, people blame themselves
- We’re not use to adversity, so the smallest stressor makes people imbalanced (e.g. financial crisis)
Nemesis-II data - how did they assess suicidality and what was the prevalence?
- Nemesis-II: Large longitudinal national study on the occurrence of mental health problems in the Netherlands
- First was in 1996, second in 2007. New wave started in 2019
- Suicidal thoughts: ‘Have you ever felt so depressed that you thought about committing suicide?’; life-time prevalence: 8.3% and 12-month prevalence: 1.1%
- Suicide attempt: this was established with the question ‘Did you ever attempt suicide?’; 2.2% and 12-month prevalence 0.1%
- When asked again about life-time suicidal attempt in a year follow-up - 25% people say no even if they said yes to a suicide attempt before (reasons: forgot that they said yes and rethink what they consider a suicide attempt) - such a straightforward question like this has a measurement error
How is depression, suicidal thoughts and suicidal attempts related?
- Of the people with suicidal thoughts, 58% had depression
- THE OTHER WAY AROUND: 26% of people with depression had suicidal thoughts
- 70% of people with a history of a suicide attempt also had depression
- THE OTHER WAY AROUND: 8.4% of people with depression also made a suicide attempt
- Of all people with suicidal thoughts, 27% will do a future suicide attempt - how do we decide who is at the highest risk of suicidal behaviour?
- 76,6% of all attempts takes place within one year after onset suicidal thoughts
The paper by O’Connor and Nock
Within the paper, they provide risk and protective factors contributing to suicide, overview of models and suggestions for psychological treatment
What role do psychiatric disorders play as the risk factors for suicidal behaviour?
- Suicidal behaviour results from complex interaction of many different factors but why these factors work together to increase the risk of this behaviour is not clear
- Most widely studied risk factor: presence of a previous psychiatric disorder - 90% of those who died by suicide had a psychiatric disorder before their death, however, most people with a psychiatric disorder never become suicidal (one study shows only 5%) → little predictive power
What does the diathesis-stress model posit about suicidality?
The negative results of pre-existing vulnerability factors are especially pronounced when activated by stress
What does the term Psychache refer to?
- Schneidman introduced the term Psychache
- Psychache - refers to the mental pain which becomes unbearable and becomes the motive for suicide (“the hurt, anguish, soreness, aching, psychological pain in the psyche, the mind”)
- psychache arises when vital psychological needs are blocked or unmet and that if psychache becomes sufficiently severe, it can become “unbearable” or “intolerable,” and in turn motivate suicide
- Suicidal behaviour always seems to be a reaction to something the person wants to escape
What model did Schneidman come up with?
- Came up with a cubic model of suicide (picture 3) that proposes that suicidal behaviour only happes if all things fall into place = psychache, pertrubation (agitation), perceived stress
- Before there was only the idea that there is depression and then it turns into suicidal behaviour but he came up with the idea that it’s a combination of the three things
What term did Mark Willims come up with?
Williams came up with the term cry of pain - suicidal behaviour is a cry for help but he said it’s better desrcibed as cry of pain because they feel like they can’t fight or flight anymore that they freeze and the only escape is suicide
What is the Arrested flight theory by Mark Williams?
He differentiates between two terms:
-
Defeat - The individual experiences a profound sense of defeat, humiliation, or failure. This may stem from personal, interpersonal or situational factors, such as a failed relationship, job loss or chronic illness
↪ Significance: These experiences lead to feelings of worthlessness, inadequacy, and a loss of status of control
↪ Defeat is seen as an evolutionary signal to withdraw from a situation where further struggle seems futile, aking to an animal signaling submission in the face of overwhelming threat -
Entrapement - A sense of being trapped in a situation from which there is no escape, either physically, socially or mentally
↪ Key mechanisms:
→ Internal entrapement: Feeling trapped by one’s own thoughts, emotions, or self-perceptions (e.g. ‘‘I can’t escape my feelings of guilt or shame - shame is a big part of suicidality)
→ External entrapement: Feeling trapped by external circumstances or social environments (e.g. abusive relationships, financial pressures)
↪ Entrapement builds on the sense of defeat, as the individual perceives no viable way to change or improve their situation
Defeat and entrapement are highely corrolated but the idea is that entrapement follows after the experience of defeat
Interpersonal theory of suicidal behaviour by Thomas Joiner
Very infuential theory - closed the gap between suicidal thoughts and actions (picture 4)
Three conditions need to be met for a person to decide that they are gonna commit a suicide
First suicidal thoughts must be there! Desire for suicide:
1. Thwarted belongingness (I am alone) - Loneliness, lack of reciprocal care, social disintegration
2. Perceived burdensomness (I am a burdem) - Self-hatred, belief in being a liability
↪ Low levels of thwarted belongingness and high levels of perceived burdensomness + being hopeless that these states won’t change, lead to the development of suicidal desire
↪ Suicidal thoughts are much more common than the attempts
↪ Suicidal Desire is a necessary though not sufficient cause for a suicide attempt; having capability for suicide increases the risk of suicide attempt
3. Capability for suicide (it’s against our nature to want to kill ourselves and have no fear of death - self-harming, less pain sensitivity, so the person really has to overcome this to take action)
↪ After this third one is met > lethal (or near-lethal) suicide attempts
The strength of this model is its simplicity
What is the Integrated motivational -volitional model of suicidal behaviour by O’Connor
O’Connor combined all the models together and created the big model with the three phases (picture 5)
He identified suicidal behaviour as really a behaviour and not just a by-product but that it has a dynamic of its own
- The motivational phase describes the factors that govern the development of suicidal ideation and intent, whereas the volitional phase outlines the factors that determine whether an individual attempts suicide
- In the motivational phase, he included defeat, entrapement, thwarted belongingness and burdensomness (the last two as moderators) from the previous theories
- He says that entrapement and feeling of defeat are the key drivers and it can be strengthened by feelings of the thwarted belongingness and burdensomness
- Volitional phase distinguishes thoughts from the behaviour - made on theory of planned behaviour
- These different phases might explain the difference between the 25% that do actually go out and attempt suicide
- There are studies that show that if you compare people who have suicidal thoughts but no attempts with people who have attempts, they differ on the variables propsed by O’Connor = capability, impulsivity, intensions (planning), access to means
↪ Important for clinicians since they can use this to distinguish between people who are in threat of suicide are those who are not
What is the network perspective on suicidal behaviour that the lecturer is working on
- They are trying to apply the network perspective to understand suicidality as a complex system
- The traditional model looks at psychological problems as something that comes from a related contruct (e.g. rumination, insomnia, hopelessness etc come from depression - suicidal thoughts could also be part of this)
- The network perspective suggests that the psychological problems interact with themselves and they think that suicidal behaviour really emerges from these factors over the course of time if the things become a loop
- They are trying to see the relationship between all these factors - this is different from a regular regression because you can see which factors influence each other more or less
What was the experiment they did to test the network model of suicidality
- 366 patients treated in scottish hospital for suicide attempt
- Within 24 hours, Beck Scale for Suicide Ideation was assessed - ask about 19 characteristics of suicidal behaviour (picture 7) so it asks about motivational factors but also volitional factors and they divided these accordingly (picture 8)
- Using national databases, it was determined how many people were treated again within 15 months - limited because those were only the people who came back to the hospital but they don’t know about people who had a suicidal attempt but never came to the hospital
- People who score high on attempt also score high on availability of methods - one factor that really separates those who only have thoughts and who take action
- Desire for suicide was the most central factors - the one most corrolated with all the other ones - so maybe focusing on this one factor in treatment could influence all the other ones
What were the results of an experiment where they compared the interpersonal theory and the integrated motivational-volitional model?
- The main difference between the two is the role of entrapement - in Joiner’s model it’s enough to have thwarted belongingness and perceived burdensomness for suicidal ideation whereas in O’Conner’s model it would be mainly entrapment and only then the other two
- With network analysis, they looked at how these factors relate
- Internal entrapement was as related to suicidal ideation as was perceived burdensomness and other factors (thwarted belongingness) then also influenced suicidal ideation but indirectly via other factors (picture 9)
What was another study which modeled suicidal ideation within an individual?
- Collected data using phones - get a notification to report their mood
- Asked for suicidal ideation, perceived burdensomness
- Results: no one has a similar patern - makes sense in reality but not from a theoretical perspective (picture 10)
- They tried to find clusters within each patient but that was also hard to predict much
- Some variables are more or less stable but other ones are flactuating over time
- What they learned from this data is that suicidal ideation fluctuates over time - very frustrating to study (makes it unpredictable)
- They saw that some symptoms flactuated together and some not (picture 11) - in some perceived burdensomness resulted in desire to kill oneself but in other it didn’t (it’s difficult to get the long-term data that fit the model)
How did they try to formalise the model and what would be the next step?
- These models are not formalised so this researcher created a model where she added lot of funky equations to formalise all the relationships mentioned in the previous models - to get a better grip on all of the factors (picture 12)
- Next step would be to use the computational models to try and to see whether we find the behaviour that we see in clinical practice
- E.g. if you have an urge to escape then you have an increase in suicidal thoughts by a certain formula = and now they are trying to use simulations to see whether these models show behaviour that you would actually expect in the clinical models
- It’s a new field of study, they are only trying to see whether it works and still don’t know a lot about it
What are the four groups that suicide risk factors can be classified in?
- personality and individual differences
- cognitive factors
- social factors
- negative life events
Personality and individual differences
Why are factors related to personality and individual difference of interest?
- they are fairly stable in adulthood
- often have known biological bases
- are affected by the environment
- effect cognition and emotion
Personality and individual differences
What are the personality and individual differences factors that contribute to risk of suicide?
- Hopelessness - important in the developement of suicidal ideation, but other factors might be more useful as predictors of suicide attempts
- Impulsivity - mixed findings on its relation tp suicide but should be considered in risk assessment, especially in young people and people with personality disorders (might predict repeated attempts)
- Socially-prescribed perfectionism (belief that other people hold unrealistically high expectations of you) - increases suicide risk by promoting a sense of social disconnection
- Big five - combination of high levels of neuroticism and low levels of extroversion increases risk for suicide
- Optimism - higher trait optimism might lower suicide risk when people are confronted with negative life events and it might act as a buffer between hopelessness and suicidal ideation (mixed evidence but might be a protective factor)
- Resilience - not enough evidence but might act as a protective factor in military personnel, misusers of alcohol and illegal drugs and prisoners; positive appraisals might buffer against the development of suicidal ideation
What are the cognitive factors that contribute to risk of suicide?
- Cognitive rigidity
- Rumination
- Thought suppression
- Autobiographical memory biases
- Belongingness and burdensomeness
- Fearlessness about injury and death and pain insensitivity - cause or result of suicidal behaviour?
- Problem solving and coping
- Agitation
- Implicit associations - between death and the self
- Attentional biases
- Future thinking - pessimism for future increases suicide risk
- Goal adjustment
- Reasons for living
- Defeat and entrapment
Cognitive factors
Cognitive rigidity
Might lead to thinking that suicide is the only option; predicted suicidal thinking
Cognitive factors
Rumination
Brooding rumination (person dwells on his or her symptoms) more strongly associated with suicidal ideation and attempts as opposed to pondering rumination (person contemplates the reasons for his or her symptoms and potential solutions)
Cognitive factors
Thought suppression
Increases the frequency of unwanted thoughts which increases risk of suicidality
Cognitive factors
Autobiographical memory biases
Decreased ability to recall specific autobiographical memories, which might in turn impair their ability to imagine the future and to engage in eff ective problem solving, thus increasing the likelihood of suicidal behaviour
Cognitive factors
Belongingness and burdensomness
Both predictors even after controlling for depressive symptoms
Cognitive factors
Personal problem solving and coping
Especially interpersonal problem solving; seems to be mostly accounted for by presence of depression
Cognitive factors
Agitation
Especially predictive of attempts in people with higher capability for suicide
Cognitive factors
Attentional biases
Recent history of suicide = greater attention to suicide-related stimuli; predicts future attempts; result or cause?
Cognitive factors
Goal adjustment
Struggling to disengage from unattainable goals and re-engage with new ones increases the risk of hospital readmission after self-harm
Cognitive factors
Reasons for living
Fewer reasons, little desire to live and moderate-to-strong desire to die increased suicide risk
What are the social factors that increase the risk of suicide?
- Family history of suicide
- Exposure to suicidal behaviour of family or friends
- Maternal suicidal behaviour associated with offspring suicidal behaviour
- Internet - needs further research because could have both positive and negative effects
- Social isolation and absence of social support
What are the negative life events factors that contribute to risk of suicide?
- Childhood adversities - abuse and family disruptions, strongly increase the risk of suicidal behavior, especially during childhood and adolescence, with the association weakening over time
- Traumatic life events during adulthood - physical and sexual abuse seem to convey the highest risk for both onset and persistence of suicidal behaviour
- Physical illness - presence and accumulation of physical illnesses increases the risk
- Other interpersonal stressors - romantic problems, legal diffi culties, loss of income, non-heterosexual orientation, bullying and victimisation
- Psychophysiological stress response - dysregulation of the hypothalamic–pituitary–adrenal axis; needs further research
Psychological treatment
- Most people with suicidal thoughts and behaviour don’t receive treatment - low perceived need and the desire to handle the problem personally
- Treatment targetting depression - not helpful in reduction of suicidality
- Limited treatment methods identifies but CBT showed to be effective in decreasing re-attempts
New interventions:
- Safety-planning interventions, which include the identification of warning signs, coping strategies, and sources of support + restriction of access to lethal means
- Mentalisation-based treatment to reduce self-harm in adolescence
Learning objectives
- Describe the prevalence and risk factors of suicidal behaviour [paraphrasing]
- Explain different theoretical models of suicidal behaviour [paraphrasing]
- Reflect on the complexity of suicidal behavior [analysing, scientific thinking]
