Staff Voices: A Look at Social Cognition and Suicide Risk
Cognitive and social cognitive processes, to include how we conceptualize ourselves and our futures, how we perceive ourselves in relation to others and the standards we establish for ourselves and others, and how adept we are at solving interpersonal dilemmas, are important risk factors for suicide.
Hopelessness
The social cognitive risk factor historically demonstrating the strongest link to suicidal ideation and behaviors has been hopelessness, defined as the perception that one’s negative life circumstances are unlikely to improve. Weishaar (2000) described hopelessness as the cognitive risk factor “most consistently related to suicide ideation, intent, and completion” in both adult and child clinical populations. Research has suggested that hopelessness may be a stronger predictor of completed suicide than depression, even when other important risk factors, to include prior history of attempts, are controlled for statistically. Hopelessness has been shown to be more predictive of suicidal intent than depression among both suicide ideators and attempters. In prospective studies, hopelessness predicted eventual suicide over a 10-year period among adult patients hospitalized with suicidal ideation and adult psychiatric outpatients. In another large-scale longitudinal study, those who expressed hopelessness at baseline were 11.2 times as likely to have died by suicide over the 13 year follow-up interval. In a more specific examination of subtypes of hopelessness, Heisel, Flett, and Hewitt (2003) found suicidal ideation to be significantly associated with both general and social hopelessness.
Perfectionism/ Elevated Standards for the Self
Perfectionism has been shown to be predictive of both suicidal ideation and attempts in both adolescent and adult samples. Some research has suggested that socially prescribed perfectionism may be the most critical form of perfectionism with respect to suicide risk, proposed to confer vulnerability to suicidal behaviors by depriving people of the benefits of social connection and by exposing them to the costs of social disconnection. Among a sample of adolescents presenting at a hospital for suicide attempts, socially prescribed perfectionism was associated with more serious suicide intent. In addition, some research has suggested that socially prescribed perfectionism is disciminantly associated with important mediators of suicidality, while self-oriented perfectionism is not.
A body of research related to perfectionism is that examining perceived attainment of standards established for the self. In one study, perceived academic failure among high school students predicted significant differences in self-esteem, locus of control, depressive symptoms, suicidal thoughts, plans, threats, deliberate self-injury, and was associated with a five-fold increase in likelihood of suicide attempt.
In a study comparing a sample of adolescent suicidal vs. non-suicidal inpatients, suicidal adolescents reported more negative self-representations, a less differentiated and less integrated organization of self-attributes, and more discrepancies between the actual and ideal/ought domains of the self, relative to control participants. Compared with psychiatric nonsuicidal participants, suicidal adolescents demonstrated a less complex organization of self-attributes and a higher discrepancy between their ideal and ought selves.
In an investigation of the link between the disparities among self-perceptions and self-evaluative standards and suicidal ideation in a sample of college students, self-perceptions which were discrepant from both ideal and ought standards were associated with suicidal ideation. Importantly, discrepancies between actual and ideal standards which a person believed were unlikely to resolve in the future were more strongly associated with suicidal ideation, highlighting the importance of belief patterns which reflect hopelessness about the likelihood of attaining one’s desired self-attributes.
Problem-Solving Deficits
Problem-solving ability, especially for interpersonal dilemmas, is a cognitive process found to be deficient in suicidal patients. In one study, only those formerly depressed individuals with a history of suicidal ideation produced significantly less effective solutions to interpersonal problems following mood challenge, an effect that was moderated by insufficient specificity in autobiographical memory. In another study, problem-solving deficiencies were shown to mediate the relationship between family history of suicide attempts and multiple suicide attempt status.
Autobiographical Memory
Research suggests that deficiencies in the ability to generate specific, detailed autobiographical memories may be associated with suicide risk. A number of prospective studies suggest that one of the maladaptive effects of overgeneralized memory is to delay recovery from affective disturbance, ultimately lengthening the time frame for suicide risk. It is argued that affective disturbance 1) may be maintained by the same ruminative processes implicated in the maintenance of an overgeneralized retrieval style, or 2) may arise more directly, secondary to deficits in adaptive cognitive functions that rely on memory and related processes, such as problem solving.
Future thinking can also be affected by overgeneral autobiographical memory deficiency. Suicidal patients have less specific memories and are able to generate less specific future scenarios compared with nonsuicidal individuals. Such failure may have an impact on the formation and implementation of future plans, possibly perpetuating hopelessness.
Finally, overgeneralized autobiographical memory has been identified as a major contributor to social problem-solving deficits among suicidal individuals, such that suicide attempters tend to retrieve more general autobiographical memory compared with non-suicidal controls. Therefore, if a suicidal individual is attempting to retrieve information from past experiences to solve a current interpersonal problem, he or she may experience more difficulty.
Perceived Burden and Thwarted Belongingness
Joiner (2005) put forth a model which incorporates perceived burden and thwarted belongingness-- the social-cognitive states he argues are most critical to the desire for death by suicide. Key is the idea that one perceives a sense of burdensomeness or lack of belongingness regardless of whether one is actually socially isolated or places burden on others.
Perceived burden and social isolation (the latter is another way to conceptualize thwarted belongingness) have stood apart as risk factors for suicide across samples. Data have supported the idea that perceived burden is a unique and specific predictor of suicide, a predictor of medical lethality of suicide attempt, and that suicide notes from individuals dying by suicide contain more references to perceived burden than the notes of individuals attempting suicide. Brown and colleagues (2002) further reported that whereas non-suicidal self-injury was often driven by a desire to express anger or punish oneself, suicide attempts were often motivated by a desire to make others better off.
In a study seeking to examine the relationship between objective and subjective social support and suicidal ideation in older adults, only lower perceived (subjective) support remained significantly associated with suicidal ideation after adjusting for other risk factors. Other studies in clinical samples, to include samples of depressed patients, found a significant association between perceived social support and suicidal ideation.
Importantly, a growing body of work has provided support for the relationship of perceived burden and social isolation to suicidal ideation, behavior, and death in military samples.
Treatment Implications
The above findings have exciting implications for the treatment of suicidal individuals. As these constructs cross DSM diagnostic boundaries, they are risk factors which can be identified independently of diagnosis. They can also be addressed specifically in the context of treatment, affording us targets for intervention beyond our standard treatment of the Axis I and Axis II diagnoses most commonly associated with suicidal ideation and behaviors.
References:
Cornette, M. M., Mathias, C. W., Marsh, D. M., deRoon-Cassini, T. A., and Dougherty, D. M. (2011). Cognition and suicide. In A. Shrivastava, M. T. Kimbrell, D. Lester (Eds.)
Suicide from a Global Perspective: Psychosocial Approaches (pp. 3-10). Nova Science Publishers Inc: Hauppauge, NY.
Michelle Cornette, Ph.D., is a Suicide Prevention Subject Matter Expert at the Center for Deployment Psychology.
Cognitive and social cognitive processes, to include how we conceptualize ourselves and our futures, how we perceive ourselves in relation to others and the standards we establish for ourselves and others, and how adept we are at solving interpersonal dilemmas, are important risk factors for suicide.
Hopelessness
The social cognitive risk factor historically demonstrating the strongest link to suicidal ideation and behaviors has been hopelessness, defined as the perception that one’s negative life circumstances are unlikely to improve. Weishaar (2000) described hopelessness as the cognitive risk factor “most consistently related to suicide ideation, intent, and completion” in both adult and child clinical populations. Research has suggested that hopelessness may be a stronger predictor of completed suicide than depression, even when other important risk factors, to include prior history of attempts, are controlled for statistically. Hopelessness has been shown to be more predictive of suicidal intent than depression among both suicide ideators and attempters. In prospective studies, hopelessness predicted eventual suicide over a 10-year period among adult patients hospitalized with suicidal ideation and adult psychiatric outpatients. In another large-scale longitudinal study, those who expressed hopelessness at baseline were 11.2 times as likely to have died by suicide over the 13 year follow-up interval. In a more specific examination of subtypes of hopelessness, Heisel, Flett, and Hewitt (2003) found suicidal ideation to be significantly associated with both general and social hopelessness.
Perfectionism/ Elevated Standards for the Self
Perfectionism has been shown to be predictive of both suicidal ideation and attempts in both adolescent and adult samples. Some research has suggested that socially prescribed perfectionism may be the most critical form of perfectionism with respect to suicide risk, proposed to confer vulnerability to suicidal behaviors by depriving people of the benefits of social connection and by exposing them to the costs of social disconnection. Among a sample of adolescents presenting at a hospital for suicide attempts, socially prescribed perfectionism was associated with more serious suicide intent. In addition, some research has suggested that socially prescribed perfectionism is disciminantly associated with important mediators of suicidality, while self-oriented perfectionism is not.
A body of research related to perfectionism is that examining perceived attainment of standards established for the self. In one study, perceived academic failure among high school students predicted significant differences in self-esteem, locus of control, depressive symptoms, suicidal thoughts, plans, threats, deliberate self-injury, and was associated with a five-fold increase in likelihood of suicide attempt.
In a study comparing a sample of adolescent suicidal vs. non-suicidal inpatients, suicidal adolescents reported more negative self-representations, a less differentiated and less integrated organization of self-attributes, and more discrepancies between the actual and ideal/ought domains of the self, relative to control participants. Compared with psychiatric nonsuicidal participants, suicidal adolescents demonstrated a less complex organization of self-attributes and a higher discrepancy between their ideal and ought selves.
In an investigation of the link between the disparities among self-perceptions and self-evaluative standards and suicidal ideation in a sample of college students, self-perceptions which were discrepant from both ideal and ought standards were associated with suicidal ideation. Importantly, discrepancies between actual and ideal standards which a person believed were unlikely to resolve in the future were more strongly associated with suicidal ideation, highlighting the importance of belief patterns which reflect hopelessness about the likelihood of attaining one’s desired self-attributes.
Problem-Solving Deficits
Problem-solving ability, especially for interpersonal dilemmas, is a cognitive process found to be deficient in suicidal patients. In one study, only those formerly depressed individuals with a history of suicidal ideation produced significantly less effective solutions to interpersonal problems following mood challenge, an effect that was moderated by insufficient specificity in autobiographical memory. In another study, problem-solving deficiencies were shown to mediate the relationship between family history of suicide attempts and multiple suicide attempt status.
Autobiographical Memory
Research suggests that deficiencies in the ability to generate specific, detailed autobiographical memories may be associated with suicide risk. A number of prospective studies suggest that one of the maladaptive effects of overgeneralized memory is to delay recovery from affective disturbance, ultimately lengthening the time frame for suicide risk. It is argued that affective disturbance 1) may be maintained by the same ruminative processes implicated in the maintenance of an overgeneralized retrieval style, or 2) may arise more directly, secondary to deficits in adaptive cognitive functions that rely on memory and related processes, such as problem solving.
Future thinking can also be affected by overgeneral autobiographical memory deficiency. Suicidal patients have less specific memories and are able to generate less specific future scenarios compared with nonsuicidal individuals. Such failure may have an impact on the formation and implementation of future plans, possibly perpetuating hopelessness.
Finally, overgeneralized autobiographical memory has been identified as a major contributor to social problem-solving deficits among suicidal individuals, such that suicide attempters tend to retrieve more general autobiographical memory compared with non-suicidal controls. Therefore, if a suicidal individual is attempting to retrieve information from past experiences to solve a current interpersonal problem, he or she may experience more difficulty.
Perceived Burden and Thwarted Belongingness
Joiner (2005) put forth a model which incorporates perceived burden and thwarted belongingness-- the social-cognitive states he argues are most critical to the desire for death by suicide. Key is the idea that one perceives a sense of burdensomeness or lack of belongingness regardless of whether one is actually socially isolated or places burden on others.
Perceived burden and social isolation (the latter is another way to conceptualize thwarted belongingness) have stood apart as risk factors for suicide across samples. Data have supported the idea that perceived burden is a unique and specific predictor of suicide, a predictor of medical lethality of suicide attempt, and that suicide notes from individuals dying by suicide contain more references to perceived burden than the notes of individuals attempting suicide. Brown and colleagues (2002) further reported that whereas non-suicidal self-injury was often driven by a desire to express anger or punish oneself, suicide attempts were often motivated by a desire to make others better off.
In a study seeking to examine the relationship between objective and subjective social support and suicidal ideation in older adults, only lower perceived (subjective) support remained significantly associated with suicidal ideation after adjusting for other risk factors. Other studies in clinical samples, to include samples of depressed patients, found a significant association between perceived social support and suicidal ideation.
Importantly, a growing body of work has provided support for the relationship of perceived burden and social isolation to suicidal ideation, behavior, and death in military samples.
Treatment Implications
The above findings have exciting implications for the treatment of suicidal individuals. As these constructs cross DSM diagnostic boundaries, they are risk factors which can be identified independently of diagnosis. They can also be addressed specifically in the context of treatment, affording us targets for intervention beyond our standard treatment of the Axis I and Axis II diagnoses most commonly associated with suicidal ideation and behaviors.
References:
Cornette, M. M., Mathias, C. W., Marsh, D. M., deRoon-Cassini, T. A., and Dougherty, D. M. (2011). Cognition and suicide. In A. Shrivastava, M. T. Kimbrell, D. Lester (Eds.)
Suicide from a Global Perspective: Psychosocial Approaches (pp. 3-10). Nova Science Publishers Inc: Hauppauge, NY.
Michelle Cornette, Ph.D., is a Suicide Prevention Subject Matter Expert at the Center for Deployment Psychology.