The impact of scaffolded and non-scaffolded suicidal virtual human interaction training on clinician emotional self-awareness, empathic communication, and clinical efficacy.

BACKGROUND: Clinicians working with patients at risk of suicide often experience high stress, which can result in negative emotional responses (NERs). Such negative emotional responses may lead to less empathic communication (EC) and unintentional rejection of the patient, potentially damaging the therapeutic alliance and adversely impacting suicidal outcomes. Therefore, clinicians need training to effectively manage negative emotions toward suicidal patients to improve suicidal outcomes. METHODS: This study investigated the impact of virtual human interaction (VHI) training on clinicians' self-awareness of their negative emotional responses, assessed by the Therapist Response Questionnaire Suicide Form, clinicians' verbal empathic communication assessed by the Empathic Communication and Coding System, and clinical efficacy (CE). Clinical efficacy was assessed by the likelihood of subsequent appointments, perceived helpfulness, and overall interaction satisfaction as rated by individuals with lived experience of suicide attempts. Two conditions of virtual human interactions were used: one with instructions on verbal empathic communication and reminders to report negative emotional responses during the interaction (scaffolded); and the other with no such instructions or reminders (non-scaffolded). Both conditions provided pre-interaction instructions and post-interaction feedback aimed at improving clinicians' empathic communication and management of negative emotions. Sixty-two clinicians participated in three virtual human interaction sessions under one of the two conditions. Linear mixed models were utilized to evaluate the impact on clinicians' negative emotional responses, verbal empathic communication, and clinical efficacy; and to determine changes in these outcomes over time, as moderated by the training conditions. RESULTS: Clinician participants' negative emotional responses decreased after two training sessions with virtual human interactions in both conditions. Participants in the scaffolded condition exhibited enhanced empathic communication after one training session, while two sessions were required for participants in the non-scaffolded condition. Surprisingly, after two training sessions, clinical efficacy was improved in the non-scaffolded group, while no similar improvements were observed in the scaffolded group. CONCLUSION: Lower clinical efficacy after virtual human interaction training in clinicians with higher verbal empathic communication suggests that nonverbal expressions of empathy are critical when interacting with suicidal patients. Future work should explore virtual human interaction training in both nonverbal and verbal empathic communication.

Using Virtual Patients to Assess and Improve Clinicians' Emotional Self-awareness: a Randomized Controlled Study.

OBJECTIVE: Working with suicidal patients can elicit negative emotional responses that can impede clinicians' empathy and affect clinical outcomes. Virtual human interactions represent a promising tool to train clinicians. The present study investigated the impact of virtual human interaction training to enhance clinicians' emotional self-awareness and empathy when working with suicidal patients. METHODS: Clinicians were randomly assigned into two groups. Both groups interviewed a virtual patient presenting with a suicidal crisis; clinicians in the intervention condition (n = 31) received immediate feedback about negative emotional responses and empathic communication, whereas those in the control condition (n = 33) did not receive any feedback. All clinicians interviewed a second virtual patient 1 week later. Clinicians' emotional response to the two virtual patients and their empathic communication with each of them were assessed immediately after each interaction. Linear mixed models were used to assess change in clinicians' emotional response and verbal empathy between the two interactions across conditions. RESULTS: Clinicians' emotional responses toward the suicidal virtual patients were unchanged in both conditions. Clinicians in the intervention condition presenting low empathy level with the first virtual patient showed higher empathy level with the second virtual patient than with the first (B = 1.15, SE = 0.25, p < 0.001, 95% CI [0.42, 1.89]). CONCLUSIONS: This work demonstrates the feasibility of using virtual human interactions to improve empathic communication skills in clinicians with poor empathy skills. Further refinement of this methodology is needed to create effective training modules for a broader array of clinicians.

Who are the patients who deny suicidal intent? Exploring patients' characteristics associated with self-disclosure and denial of suicidal intent.

BACKGROUND: Patients' non-disclosure of suicidal ideation and intent concealment represent a major obstacle to the effective assessment of suicide risk and to the delivery of suicide prevention treatments. The present study aimed to investigate this phenomenon and to assess (1) if outpatient psychiatric patients are more or less likely to disclose intent to mental health clinicians in the context of psychiatric/psychological treatment than they are to in the context of research interviews with non-clinicians; and (2) if certain demographic, trait-like, and state-like characteristics may predict such disclosure differences. METHODS: A total of 780 psychiatric outpatient participants aged 18 to 84 and 193 clinician participants aged 25 to 54 were included in the study. The proportion of patients who disclosed to clinicians only, to research assistants (RAs) only, to both, and to none, was compared using a z-test. Univariate analyses were used to compare the participants' variables across disclosure groups, and significant individual predictors were included in multilevel regression analyses. RESULTS: Participants were more significantly more likely to disclose to RAs (10.4%) than to clinicians (5.6%), p < 0.001. Neuroticism and trait anxiety predicted disclosure to RAs vs no disclosure; low extraversion predicted disclosure to clinician versus no disclosure; and extraversion and trait anxiety predicted disclosure to RAs versus to clinicians. DISCUSSION: Patients' disclosure patterns, the personality variables predicting them, and their clinical implications were discussed in the context of the extant literature on patients' reasons for concealing suicidal ideation and intent.

Stressful Life Events and Near-term Suicidal Risk in a Clinical Population.

The present study examined 22 specific stressful life events (SLEs) in relation to recent and prospective suicidal thoughts and behaviors (STBs). The effect of assessment method (self-report vs. chart-based ratings) and inpatient/outpatient status was also investigated. Past 3-month STBs and SLEs were assessed for 1,058 psychiatric patients; 696 completed one-month follow-up assessments. SLEs were common, with 684 participants (64.7%) reporting at least one. Total number of SLEs correlated with recent and prospective STB. A higher incidence of SLE's was found with self-report vs. chart-based measures (on 20 SLEs) and inpatients vs. outpatients (on 7 SLEs). SLEs of interpersonal rejection and loss, homelessness and academic failure offered elevated risk. In sum, SLEs are common and associated with STBs in psychiatric patients. SLEs of interpersonal rejection and loss, homelessness and academic failure may merit increased clinical attention.

The relationship between anger and suicidal ideation: Investigations in two samples.

OBJECTIVES: Suicidal ideation (SI) nearly always precedes lethal suicide attempts. Anger may play a role in SI, but this appears to vary by gender and nuances in this relationship are unclear. METHOD: We investigated whether levels of (a) anger and (b) SI vary by gender, (c) the cross-sectional relationship between anger and SI, and (d) if gender moderates that relationship in two samples: adults seeking care for excessive anger (Study 1) and undergraduates endorsing previous suicide attempt (Study 2). RESULTS: In Study 1, anger was more commonly endorsed in women; however, in Study 2, anger did not vary by gender. In both studies, SI did not vary by gender. Further, in both studies, anger and SI were positively related. The relationship between anger and SI did not vary by gender in either study. CONCLUSIONS: The strength of the relationship between anger and SI did not vary by gender.

Validity of the modular assessment of risk for imminent suicide in predicting short-term suicidality.

OBJECTIVE: The Modular Assessment of Risk for Imminent Suicide (MARIS) is a clinical assessment tool, consisting of four modules assessing (1) a pre-suicidal cognitive-affective state (Module 1); (2) patients' attitudes toward suicide (Module 2); (3) clinicians' assessment of suicide risk factors (Module 3); and (4) clinicians' emotional responses to patients (Module 4) that assesses short-term suicide risk. Initial evidence provided evidence for its reliability and concurrent validity. The present study extended these findings by examining the MARIS's predictive validity in relation to suicidal thoughts and behaviors at one-month follow-up. METHODS: A sample of 1039 psychiatric patients (378 inpatients, 661 outpatients) and their clinicians (N = 144) completed a battery of measures at baseline; 670 patients completed the one-month follow-up assessment. RESULTS: MARIS total scores predicted suicidal thoughts and behaviors at one-month follow-up, even after controlling for baseline suicidal thoughts and behaviors. Moreover, both Module 1 and the Distress subscale of Module 4 were uniquely associated with suicidal thoughts and behaviors at one-month follow-up, controlling for baseline suicidal thoughts and behaviors. Modules 2 and 3, on the other hand, exhibited poor internal consistency. CONCLUSION: Overall, both patient- and clinician-rated indices are uniquely predictive of suicidal thoughts and behaviors at one-month follow-up, highlighting the need for integrating clinicians' emotional responses into suicide risk assessment. Pending replication and extension of these findings in external samples, a briefer, two-module version of MARIS (MARIS-2) may be such an integrative, psychometrically sound, and clinically useful instrument that can be utilized to assess short-term suicide risk.

Are all pain tolerance tasks the same? Convergent validity of four behavioral pain tolerance tasks, self-reported capability for suicide, and lifetime self-injurious behaviors.

OBJECTIVES: Discrepancies persist regarding the extent to which different pain measures provide similar information and relate to capability for suicide and self-injurious behaviors. This study examined pain threshold, tolerance, and persistence across four modalities (cold, heat, pressure, shock) and assessed associations with self-reported capability for suicide, non-suicidal self-injury (NSSI), and suicide attempts. METHODS: A sample of 211 students who reported lifetime suicidal ideation completed four behavioral pain tasks and self-reported on capability for suicide, NSSI, and self-injurious behaviors. RESULTS: All pain thresholds, tolerances, and persistences were positively correlated across the four tasks. Pain facets were related to self-reported capability for suicide with small effect sizes but generally did not differ across suicide attempt or NSSI histories. CONCLUSIONS: Pain thresholds, tolerances, and persistences demonstrated convergent validity across the four modalities, suggesting that these tasks provide similar information. Although the relation between pain and self-injurious behaviors remains unclear, these tasks can generally be used interchangeably.

Suicidality in Chronic Illness: An Overview of Cognitive-Affective and Interpersonal Factors.

Suicide rates are elevated in individuals with chronic illness, yet few studies have examined risk factors for suicide in this population. Drawing from theoretical models and risk factors identified in the suicide literature more broadly, this article provides a conceptual overview of cognitive (e.g., pain catastrophizing, self-criticism), affective (e.g., emotion dysregulation), interpersonal (e.g., perceived burdensomeness, thwarted belongingness, critical expressed emotion), and behavioral factors that may contribute, at least in part, to the link between chronic illness, and illness-specific factors, and suicidal thoughts and behaviors. We also outline several avenues for future research in this area and provide specific considerations and recommendations for the screening, assessment, and initial intervention of suicide risk within individuals with chronic health conditions.

Self-criticism, interpersonal conditions, and biosystemic inflammation in suicidal thoughts and behaviors within mood disorders: A bio-cognitive-interpersonal hypothesis.

We review the theoretical and empirical literature on the role of self-concept in suicidal behavior in the context of mood disorders (i.e., unipolar depression and bipolar spectrum disorders). The main themes emanating from this review are then juxtaposed against (a) the Interpersonal-Psychological Theory of Suicide and (b) biological research on the role of inflammatory processes in suicidality. Such a juxtaposition paves the way for a bio-cognitive-interpersonal hypothesis. Pathologies of the self-concept-primarily self-criticism-propel mood disorder sufferers to generate interpersonal stress that culminates in two proximal causes of suicidality: thwarted belongingness and perceived burdensomeness. In turn, these two interpersonal conditions set in motion systemic biosystemic inflammation, serving as a proximal cause for suicidality in mood disorders. We conclude by describing a research project aimed at testing this hypothesis, and by outlining pertinent implications for assessment, treatment, and prevention.

Examining the association between body trust and body mass index with quantile regression.

PURPOSE: Schachter's externality theory posits a connection between the inability to eat according to internal cues and higher body mass index (BMI); however, related work has not investigated associations between body trust and the wide range of BMIs found in general samples. This study examined the association between body trust and BMI across levels of BMI to determine whether this relationship differed as a function of BMI level. METHODS: Participants were 534 adults (55.4% female), mean age 36 years, BMIs 15.13-67.90 (M = 27.89, SD = 7.25), recruited via MTurk. They completed self-report assessments of body trust, height, and weight. Quantile regression was utilized to estimate effects of body trust on BMI at five equidistant quantiles of BMI. RESULTS: Overall linear regression analyses indicated that body trust was significantly negatively associated with BMI. Quantile regression revealed a significant negative relationship at each quantile of BMI, and Wald tests indicated the association was significantly stronger at the 0.7 and 0.9 quantiles than at the 0.1, 0.3, and 0.5 quantiles, which did not differ. CONCLUSIONS: Quantile regression identified a stronger relationship between body trust and BMI at 0.7 and 0.9 quantiles than at 0.1, 0.3, and 0.5 quantiles of BMI. Results align with the externality hypothesis, which suggests those at higher weights experience difficulty using internal cues to guide eating. A weaker-than-expected association between body trust and low BMI may be due to restricted range (few low-BMI participants). Replication in eating disorder samples is merited. LEVEL OF EVIDENCE: Level V, cross-sectional descriptive study.

Interoceptive deficits, non-suicidal self-injury, and suicide risk: a multi-sample study of indirect effects.

BACKGROUND: Interoceptive deficits (ID) have been associated with non-suicidal self-injury (NSSI) and suicidal behavior in multiple studies. Many of these studies are limited in scope, and have not fully examined possible mechanisms explaining how ID affect suicidal behavior. METHODS: This study assesses how self-reported ID relate to suicide ideation and attempts in six distinct and geographically diverse samples of adults (n = 2706) and one sample of adolescents (n = 436). Participants responded to a variety of self-report questionnaires and interviews. RESULTS: Contrary to our hypothesis, self-reported ID were only associated with suicidal ideation in two samples, one of which was the adolescent sample. Largely consistent with our predictions, self-reported ID exhibited an indirect effect on suicide attempts through versatility of NSSI in four of the five adult samples tested. Finally, the indirect effects of self-reported ID on suicide attempts through NSSI versatility did not act indirectly through behaviorally assessed pain tolerance. CONCLUSIONS: We found that, in adults, self-reported ID are not associated with suicidal ideation, but are connected with a history of suicide attempts, through an indirect effect via NSSI. Our findings also indicate that the mechanism of action leading from self-reported ID to suicidal behavior may differ between adolescents and adults, and relate to suicidal behavior independent of pain tolerance. Clinical implications and future directions are discussed.

Examining the link between prior suicidality and subsequent suicidal ideation among high-risk US military service members.

BACKGROUND: Research is needed to identify the factors that explain the link between prior and future suicidality. This study evaluated possible mediators of the relationship between: (1) the severity of prior suicidality and (2) suicidal ideation severity at 3-month follow-up among a sample of high-risk military personnel. METHODS: US military service members referred to or seeking care for suicide risk (N = 624) completed self-report psychiatric domain measures and a clinician interview assessing prior suicidality severity at baseline. Three months later, participants completed a self-report measure of suicidal ideation severity. Three separate percentile bootstrap mediation models were used to examine psychiatric factors (i.e. alcohol abuse, anxiety sensitivity, hopelessness, insomnia, posttraumatic stress symptoms, suicidal ideation, and thwarted belongingness) as parallel mediators of the relationship between prior suicidality severity (specifically, suicidal ideation, suicide attempt, and overall suicidality - i.e. ideation/attempt severity combined) at baseline and suicidal ideation severity at follow-up. RESULTS: Hopelessness, specifically, and the total effect of all mediators, each significantly accounted for the relationship between prior suicidality severity and subsequent ideation severity across models. In the models with attempt severity and overall suicidality severity as predictors, thwarted belongingness was also a significant mediator. CONCLUSIONS: Hopelessness, thwarted belongingness, and overall severity of psychiatric indices may explain the relationship between prior suicidality severity and future suicidal ideation severity among service members at elevated suicide risk. Research is needed to replicate these findings and examine other possible mediators.

Psychotic symptoms and suicidal ideation in child and adolescent bipolar I disorder.

OBJECTIVES: The purpose of this study was to explore associations between specific types of hallucinations and delusions and suicidal ideation in a sample of children and adolescents with bipolar I disorder. METHODS: Participants (N = 379) were children and adolescents aged 6-15 years (M = 10.2, SD = 2.7) with DSM-IV diagnoses of bipolar I disorder, mixed or manic phase. The study sample was 53.8% female and primarily White (73.6% White, 17.9% Black, and 8.5% Other). Presence and nature of psychotic symptoms, suicidal ideation, and functioning level were assessed through clinician-administered measures. A series of logistic regressions was performed to assess the contribution of each subtype of psychotic symptom to the presence of suicidal ideation above and beyond age, sex, socio-economic status, age at bipolar disorder onset, and global level of functioning. RESULTS: Hallucinations overall, delusions of guilt, and number of different psychotic symptom types were uniquely associated with increased odds of suicidal ideation after accounting for covariates. Other forms of delusions (eg, grandiose) and specific types of hallucinations (eg, auditory) were not significantly uniquely associated with the presence of suicidal ideation. CONCLUSIONS: Findings of this study suggest the presence of hallucinations as a whole, delusions of guilt specifically, and having multiple concurrent types of psychotic symptoms are associated with the presence of suicidal ideation in children and adolescents with bipolar I disorder. Psychotic symptom subtypes, as opposed to psychosis as a whole, are an under-examined, potentially important, area for consideration regarding suicidal ideation in pediatric bipolar I disorder.

An investigation of indirect effects of personality features on anorexia nervosa severity through interoceptive dysfunction in individuals with lifetime anorexia nervosa diagnoses.

OBJECTIVE: This study examined a hypothesized pathway by which interoceptive dysfunction accounted for associations between personality features (harm avoidance, self-directedness, and perfectionism) and anorexia nervosa (AN) severity (indicated by drive for thinness, eating disorder-related preoccupations and rituals, and body mass index). METHOD: The study sample (n = 270, mean age = 28.47, 95.2% female, 98% White/Caucasian) consisted of probands and biological relatives who met DSM-IV criteria for lifetime diagnoses of AN (omitting criterion D, amenorrhea) drawn from the Price Foundation Anorexia Nervosa Affected Relative Pairs Study (AN-ARP). Participants completed measures assessing personality, interoceptive dysfunction, and eating pathology. RESULTS: Associations between personality features of low self-directedness and high perfectionism and indicators of AN severity (drive for thinness and eating disorder-related preoccupations and rituals) were significant, as were the hypothesized indirect pathways through interoceptive dysfunction. Neither harm avoidance nor body mass index was significantly related to other study variables, and the proposed indirect pathways involving these variables were not significant. DISCUSSION: Findings suggest that certain personality features may relate to AN severity, in part, through their associations with interoceptive dysfunction. Future research should examine prospective associations and the value of interventions targeting interoceptive dysfunction for interrupting the link between personality and AN severity.

The necessity, validity, and clinical utility of a new diagnostic entity: Acute suicidal affective disturbance.

OBJECTIVE: Here we argue for the necessity, validity, and clinical utility of a new diagnostic entity, acute suicidal affective disturbance (ASAD). METHOD: We expand on the conceptual, clinical, and practical rationale for ASAD, propose its defining features, describe research results to date, and suggest avenues for future research. RESULTS: There is accruing evidence for the existence of a previously unclassified, rapid-onset mood disturbance that geometrically escalates and regularly results in life-threatening behavior. CONCLUSIONS: ASAD research may not only improve the field's understanding of suicidal behavior but also enhance clinical effectiveness and save lives.

Investigating the reliability of suicide attempt history reporting across five measures: A study of US military service members at risk of suicide.

OBJECTIVE: Utilizing a sample of military service members at risk of suicide, this study aimed to: (a) identify patterns of suicide attempt (SA) history reporting across five measures and (b) evaluate whether consistent SA reporters (i.e., individuals who consistently report an SA history across measures) differ from inconsistent SA reporters on other clinical severity indices. METHOD: Participants (N = 984) completed five validated SA history measures and self-report psychiatric symptom measures. RESULTS: Of the sample, 35.4% inconsistently responded to SA history measures. Inconsistent reporters disclosed more severe suicide threat histories than consistent reporters. On all other clinical severity indices, inconsistent reporters evinced either less severe or comparable symptom levels. CONCLUSIONS: A nontrivial portion of service members may respond inconsistently to different assessments of SA history. Research is needed to identify factors that account for inconsistent SA history reporting and to improve the accuracy of SA history assessments among military personnel.

Exercise dependence: Associations with capability for suicide and past suicidal behavior.

OBJECTIVE: Exercise dependence has been linked to capability for suicide and suicidal behavior; however, less understood are which facets of exercise dependence confer risk for suicidal behavior and the potential mechanisms of this association. This study examined relationships between exercise dependence, capability for suicide, and past suicidal behavior. METHODS: A sample of 540 individuals recruited via MTurk completed online measures of their exercise dependence, capability for suicide, and history of suicidal behavior. RESULTS: Suicide attempters reported higher levels of continuance in exercise despite physical or psychological consequences, lack of control over exercise, and reductions in other activities due to exercise than nonattempters. Capability for suicide accounted for the relationship between continuance in exercise despite adverse consequences and lifetime number of suicide attempts. CONCLUSIONS: When exercise becomes pathological in the form of exercise dependence, steps should be taken to reduce such engagement due to its observed association with suicidal behavior.

Body trust as a moderator of the association between exercise dependence and suicidality.

OBJECTIVES: Exercise dependence and interoceptive deficits, particularly low body trust, have been associated with suicidality. This study tested whether low body trust predicted current suicidal ideation and past suicide attempts in individuals exhibiting symptoms of exercise dependence. METHODS: 540 individuals (55.6% female, mean age 36) recruited via MTurk completed online measures of exercise dependence, interoception, and history of suicidal ideation and attempts. RESULTS: Exercise dependence symptoms and low body trust were associated with suicidal ideation. Body trust moderated the relationship between exercise dependence symptoms and suicidal ideation. Continuance in exercise despite adverse consequences and low body trust were associated with past suicide attempts. CONCLUSIONS: Body trust was associated with suicidal ideation and suicide attempts in individuals with exercise dependence symptoms, and the associations strengthened as body trust decreased. The experience of not trusting one's own body may exacerbate suicide risk in at-risk individuals.

Atypical and Severe Nonsuicidal Self-Injury as an Indicator of Severe Psychopathology: Findings From a Sample of High-Risk Community Mental Health Clients.

This study examined whether atypical/severe nonsuicidal self-injury (NSSI; e.g., foreign body ingestion, cutting necessitating sutures) serves as a marker of severe psychopathology among 467 adult community mental health clients (n = 33 with an atypical/severe NSSI history). Information regarding psychiatric risk indicators was extracted from participants' psychiatric records. Generalized linear models with negative binomial distribution and log link function, as well as chi-square tests, were used to address study aims. Clients with a lifetime atypical/severe NSSI history met criteria for a significantly greater number of psychiatric risk indicators than clients with a lifetime history of common NSSI only; however, these clients were not significantly more likely to report recent suicidal actions. Individuals with an atypical/severe NSSI history may demonstrate more severe psychopathology than those with a history of common NSSI only. Thus, it may be clinically useful to consider individuals with an atypical/severe NSSI history as a high-risk subgroup.

Anxiety, depression, and the suicidal spectrum: a latent class analysis of overlapping and distinctive features.

Anxiety and depression diagnoses are associated with suicidal thoughts and behaviours. However, a categorical understanding of these associations limits insight into identifying dimensional mechanisms of suicide risk. This study investigated anxious and depressive features through a lens of suicide risk, independent of diagnosis. Latent class analysis of 97 depression, anxiety, and suicidality-related items among 616 psychiatric outpatients indicated a 3-class solution, specifically: (1) a higher suicide-risk class uniquely differentiated from both other classes by high reported levels of depression and anxious arousal; (2) a lower suicide-risk class that reported levels of anxiety sensitivity and generalised worry comparable to Class 1, but lower levels of depression and anxious arousal; and (3) a low to non-suicidal class that reported relatively low levels across all depression and anxiety measures. Discriminants of the higher suicide-risk class included borderline personality disorder; report of worthlessness, crying, and sadness; higher levels of anxious arousal and negative affect; and lower levels of positive affect. Depression and anxiety diagnoses were not discriminant between higher and lower suicide risk classes. This transdiagnostic and dimensional approach to understanding the suicidal spectrum contrasts with treating it as a depressive symptom, and illustrates the advantages of a tripartite model for conceptualising suicide risk.