Personality disorder traits, risk factors, and suicide ideation among older adults.

BACKGROUND: Personality disorder traits are relatively prevalent among older adults, and can be associated with complex and chronic difficulties, including suicide risk. However, there is a lack of research regarding personality disorders and suicide ideation in older adults. Depressive symptoms and hopelessness may be important to the relation between personality disorders and suicide risk. Additionally, variables from the interpersonal theory of suicide, perceived burdensomeness and thwarted belongingness, may be critical risk factors for suicide in this population. We hypothesized that perceived burdensomeness and thwarted belongingness, theory-based variables, would act as parallel mediators of the relation between personality disorder traits and suicide ideation, whereas depressive symptoms and hopelessness would not. METHODS: The hypothesis was tested in a sample of 143 older adults recruited from a primary care setting. Participants completed self-report questionnaires of personality traits, suicide ideation, depressive symptoms, hopelessness, perceived burdensomeness, and thwarted belongingness. RESULTS: Findings from a non-parametric bootstrapping procedure indicated that perceived burdensomeness, thwarted belongingness, and depressive symptoms mediated the relation between total personality disorder traits and suicide ideation. Hopelessness did not act as a mediator. CONCLUSIONS: These findings indicate that perceived burdensomeness, thwarted belongingness, and depressive symptoms are likely important risk factors for suicide ideation among older adults. Clinicians should be aware of these issues when assessing and treating suicide risk among older adults.

The Mediating Role of Perceived Burdensomeness in Relations Between Domains of Cognitive Functioning and Indicators of Suicide Risk.

OBJECTIVES: Psychiatric inpatients are at elevated risk for suicide, but there are mixed findings regarding cognitive functioning (i.e., executive functioning and problem-solving abilities) and suicide risk in this population. We hypothesized that a mediating variable (i.e., perceived burdensomeness) may explain these mixed findings. METHOD: This hypothesis was tested in a sample of psychiatric inpatients admitted for suicide-related concerns (N = 110; 58.18% female, M(age) = 36.45) using a nonparametric bootstrapping procedure. RESULTS: Perceived burdensomeness did not act as a mediator between any domain of cognitive functioning and current suicide ideation nor presence of recent suicide attempts. However, perceived burdensomeness was the strongest predictor of suicide ideation and mediated the relation between objective problem-solving skill and suicide risk (a weighted variable comprising current ideation and previous attempts). CONCLUSIONS: Perceived burdensomeness may be associated with elevated suicide ideation, suggesting that perceived burdensomeness should be assessed to inform suicide risk decisions.

Interpersonal Trauma and Suicide Ideation: The Indirect Effects of Depressive Symptoms, Thwarted Belongingness, and Perceived Burden.

Suicide risk is elevated among college-aged students and individuals exposed to cumulative interpersonal trauma. This study used the interpersonal theory of suicide as a framework to test the relation between cumulative interpersonal trauma and suicide ideation through the indirect effects of cumulative interpersonal trauma via depression, thwarted belongingness (TB), and perceived burdensomeness (PB), in serial. Participants were 261 college students who endorsed prior trauma and completed cross-sectional study measures online. An atemporal serial mediation model indicated that cumulative interpersonal trauma significantly and indirectly related to suicide ideation through depressive symptoms, TB, and PB. The relation between cumulative interpersonal trauma and suicide ideation was explained by greater depressive symptoms, TB, and PB, in serial. Therefore, depressive symptoms, TB, and PB may be important modifiable clinical targets for college students with a history of cumulative interpersonal trauma.

The acquired capability for suicide: a comparison of suicide attempters, suicide ideators, and non-suicidal controls.

BACKGROUND: The Interpersonal Theory of Suicide states that to make a serious or lethal suicide attempt, a person must experience reductions in fear and pain sensitivity sufficient to overcome self preservation reflexes (i.e., the acquired capability for suicide). The purpose of this study was to examine the fearlessness component of the acquired capability for suicide using self-report assessment instruments and an objective measure of aversion (the affectively modulated startle reflex task). METHODS: Depressed suicide ideators (n=15), depressed suicide attempters (n=15), and a group of control participants (n=14) were compared on their self-report of acquired capability and painful and provocative life events, and completed the affectively modulated startle reflex task. This task compared electromyography recordings of participants' eye-blink response to a startle probe while viewing pictures of varying hedonic valence (neutral, positive, negative, and suicide-related). RESULTS: Suicide attempters reported the highest levels of fearlessness and pain insensitivity and a greater history of painful and provocative life events. Although no group differences were found on the psychophysiology data, participants reacted to suicide-related images with less aversion compared to neutral images with no differences between suicide-related and positive images. CONCLUSIONS: Self-reported fearlessness and pain insensitivity can differentiate suicide attempters and suicide ideators. Results suggest that one's self-perception (i.e., cognitions regarding fear and pain tolerance) are more functionally related to suicide attempts than psychophysiological reactivity to suicide-related stimuli.

Understanding the Transition from Suicidal Desire to Planning and Preparation: Correlates of Suicide Risk within a Psychiatric Inpatient Sample of Ideators and Attempters.

BACKGROUND: There is a clear need to better understand the trajectory from suicidal ideation to enactment of lethal suicidal behavior. Identification of factors that promote desire and the transition to intent and behavior is critical for the advancement of theory, risk formulation, and prevention. METHOD: In this cross sectional study, correlates of suicide risk were examined at theoretically distinct points along the trajectory from suicidal thinking to behavior (i.e., desire, plans and preparations, suicide attempt) in a manner consistent with the Three-Step Theory and an ideation-to-action framework. The sample included 197 adult inpatients (60% male, 40% white) hospitalized due to ideation or a recent suicide attempt. RESULTS: Psychological pain and fearlessness about death were associated with desire and plans and preparations for suicide. There were no significant differences in suicide risk correlates between ideators and attempters. LIMITATIONS: The primary limitations of the current study relate to the cross-sectional design and the nature of the sample, which do not allow for inference of causal relations, or generalizability to outpatient and community samples or to individuals who die by suicide. CONCLUSIONS: Psychological pain and fearlessness about death may function as transitional factors that are associated with the transition from desire to suicidal intent in psychiatric inpatients. Findings have important implications for clinical practice. Treatment interventions should reduce psychological pain, increase safety, and reduce access to means.

Veteran Participation in Intensive Suicide Research Protocols: No Evidence of Iatrogenic Effects.

Suicide research remains fraught with ethical and methodological issues, including researchers' reservations about conducting intensive suicide research protocols due to potential iatrogenic effects and liability concerns. Such issues significantly impede scientific inquiry related to suicide. To date, no research has explored potential iatrogenic effects of intensive, nontreatment suicide research among Veterans. This study aimed to fill this gap. It was hypothesized that participation in suicide-specific protocols would not significantly increase risk among Veterans. Veterans completed self-reports, structured interviews, and rigorous suicide-specific tasks (Study A, N = 34; Study B, N = 18; Study C, N = 119). Findings indicated there were no significant differences in pre- and postassessment suicide risk variables (all ps > .05). Estimated mean change for "urge to harm self" was -0.24 (95% confidence interval [CI]: -0.60, 0.13), -0.28 (CI: -0.56, 0.01), and -0.01 (CI: -0.09, 0.07) and "intent to harm self" was -0.18 (95% CI: -0.45, 0.10), 0 (CI: -0.17, 0.17), and 0.01 (CI: -0.04, 0.06) for Studies A, B, and C, respectively. Results indicated the respective protocols did not produce iatrogenic effects. The current findings are discussed with attention to safety-monitoring techniques that may reduce iatrogenic effects and considerations for future researchers.

Thwarted Interpersonal Needs and Suicide Ideation Distress Among Psychiatric Inpatients: The Moderating Role of Criminal Associates.

Psychiatric inpatients are at elevated risk of suicide, and approximately half are criminal justice-involved. Their involvement with criminal associates may be linked to increased suicide ideation distress; however, this has not been examined. This study tested main effects of, and interactions between, thwarted belongingness (TB) or perceived burdensomeness (PB), time spent with associates, and associates' criminal involvement predicting suicide ideation distress. In our study, psychiatric inpatients (n = 139) completed assessments cross-sectionally. Results indicated that TB, PB, and associates' criminal involvement were significantly related to greater suicide ideation distress. A significant three-way interaction indicated participants who endorsed high TB, spent more time with associates, and had associates high in criminal involvement had the greatest probability of "Extreme" suicide ideation distress. These findings suggest that spending time with criminal associates may increase suicide ideation distress more than not having social interactions. Implications and limitations of this study are discussed.

Painful and provocative events scale and fearlessness about death among Veterans: Exploratory factor analysis.

BACKGROUND: The interpersonal theory of suicide suggests three proximal risk factors for suicide: perceived burdensomeness, thwarted belongingness, and acquired capability. Previous literature indicates that repetitive exposure to painful and provocative events is related to increased acquired capability for suicide. Despite this, research related to the assessment of painful and provocative events has been insufficient. Research has inconsistently administered the Painful and Provocative Events Scale (PPES; a painful and provocative events assessment), and no study has examined the factor structure of the English PPES. This study explored the factor structure of the PPES and the relation between factors and fearlessness about death. METHODS: The sample was a cross-sectional, self-report study comprised of 119 Veterans (Mage = 46.5, SD = 13.5). RESULTS: Findings from an exploratory factor analysis indicated a four-factor solution for the PPES; however, no factor from the PPES significantly related to fearlessness about death (measured by the Acquired Capability for Suicide Scale - Fearlessness About Death Scale; all p >.21). LIMITATIONS: Cross-sectional, small Veteran sample. CONCLUSIONS: Findings suggest that the PPES lacks the psychometric properties necessary to reliably investigate painful and provocative factors. Consequently, this measure may not reliably capture and explain how painful and provocative events relate to fearlessness about death, which is a barrier to improving suicide risk assessment and prediction. Recommendations for the construction of a new PPES are offered.

Suicide risk in older adults: evaluating models of risk and predicting excess zeros in a primary care sample.

Research is needed that examines theory-based risk factors for suicide in older adults. The interpersonal theory of suicide (Joiner, 2005; Van Orden et al., 2010) provides specific hypotheses regarding variables that contribute to the development and variability in death ideation and suicide ideation; however, data suggest that older adults may not report suicide ideation in research settings or to treatment providers even when they experience it (Heisel et al., 2006). The purpose of this study was to test theory-based predictions regarding variables that contribute to death ideation (i.e., a passive wish to die) and suicide ideation in older adults. This study introduces the application of zero-inflated negative binomial regression (ZINB) to the study of suicidal behavior. ZINB was used to test theory-based predictions, while also testing a hypothesis regarding variables associated with denial of suicide ideation among participants who endorsed risk factors associated with suicide risk. Participants included 239 adults aged 60 and older recruited from primary care clinics who completed a variety of self-report instruments. The results of this study indicated that perceived burdensomeness and hopelessness were significantly associated with variability in death ideation. Additional results indicated that elevated scores on thwarted belonging, the interaction between perceived burdensomeness and hopelessness, and the interaction between thwarted belonging and perceived burdensomeness were associated with a significant reduction in the probability of a participant being a suicide ideator. These results offer substantial support for the interpersonal theory of suicide. The implications of these findings are discussed.

The moderating effect of the negative impact of recent life events on the relation between intrinsic religiosity and death ideation in older adults.

Researchers tested the hypothesis that the negative impact of recent life events would moderate the relationship between intrinsic religiosity and death ideation in older adults. Participants (n = 272) completed assessments of death ideation, intrinsic religiosity, and negative impact of recent life events. We confirmed the presence of concurrent moderation and found that older adults with greater negative impact of recent life events and high intrinsic religiosity reported greater death ideation. These relatively surprising findings may be due to reduced fear of death in intrinsically religious older adults, an explanation consistent with previous research.