The Relational Approach to Treating Self-Harm (RELATE): study protocol for a feasibility randomised controlled trial study of cognitive analytic therapy for adults who self-harm versus treatment at usual.

BACKGROUND: Self-harm is a prevalent behaviour that has a major detrimental impact on a person's life. Psychological therapies have the potential to help, but evidence of effective interventions remains limited. Access and acceptability of interventions can also be a significant challenge, with individuals either being unable to access help or having to endure long waiting lists. Cognitive analytic therapy (CAT) is a time-limited and relationally-focused psychotherapy that may provide a valuable treatment option for people who self-harm. This protocol outlines the methodology for the first feasibility randomised controlled trial (RCT) of CAT for adults that self-harm. The trial will aim to determine the feasibility, acceptability and safety of undertaking larger-scale evaluations of CAT for self-harm within an RCT context. METHOD: An RCT design with 1:1 allocation to CAT plus treatment as usual (TAU) or TAU alone. Participants will be adult outpatients with three or more instances of self-harm in the past year (target sample of n = 60). CAT will be 8 one-to-one weekly 60-min sessions plus a follow-up session up to 8 weeks after the last session. Assessments will occur at baseline, 12 weeks and 18 weeks after randomisation. Qualitative interviews with participants will gain insights into the feasibility and acceptability of CAT. Feasibility outcomes will be judged against progression criteria. DISCUSSION: CAT may be an effective and accessible treatment option for people who self-harm, providing a more relationally orientated alternative to more behavioural therapies. The proposed feasibility RCT is an important first step in evaluating CAT as a treatment for self-harm. TRIAL REGISTRATION: The trial was pre-registered (21/10/22) on ISR CTN (ISRCTN code: ISRCTN75661422).

The Mental Imagery for Suicidality in Students Trial (MISST): study protocol for a feasibility randomised controlled trial of broad-minded affective coping (BMAC) plus risk assessment and signposting versus risk assessment and signposting alone.

BACKGROUND: Going to university is an important milestone in many people's lives. It can also be a time of significant challenge and stress. There are growing concerns about mental health amongst student populations including suicide risk. Student mental health and counselling services have the potential to prevent suicide, but evidence-based therapies are required that fit these service contexts. The Broad-Minded Affective Coping intervention (BMAC) is a brief (6 sessions), positive imagery-based intervention that aims to enhance students access to past positive experiences and associated emotions and cognitions. Pilot data provides preliminary support for the BMAC for students struggling with suicidal thoughts and behaviours, but this intervention has not yet been evaluated in the context of a randomised controlled trial (RCT). The Mental Imagery for Suicidality in Students Trial (MISST) is a feasibility RCT that aims to determine the acceptability and feasibility of evaluating the BMAC as an intervention for university students at risk of suicide within a larger efficacy trial. Key feasibility uncertainties have been identified relating to recruitment, retention, and missing data. Intervention acceptability and safety will also be evaluated. METHOD: MISST is a feasibility randomised controlled trial design, with 1:1 allocation to risk assessment and signposting plus BMAC or risk assessment and signposting alone. Participants will be university students who self-report experiences of suicidal ideation or behaviour in the past 3 months. Assessments take place at baseline, 8, 16, and 24 weeks. The target sample size is 66 participants. A subset of up to 20 participants will be invited to take part in semi-structured qualitative interviews to obtain further data concerning the acceptability of the intervention. DISCUSSION: The BMAC intervention may provide an effective, brief talking therapy to help university students struggling with suicidal thoughts that could be readily implemented into university student counselling services. Depending on the results of MISST, the next step would be to undertake a larger-scale efficacy trial. TRIAL REGISTRATION: The trial was preregistered (17 December 2021) on ISRCTN (ISRCTN13621293) and ClinicalTrials.gov (NCT05296538).

The inter-connections between self-harm and aggressive behaviours: A general network analysis study of dual harm.

Dual harm is the co-occurrence of self-harm and aggression during an individual's lifetime. This behaviour is especially prevalent within criminal justice and forensic settings. The forms of aggression that should be included in the definition of dual harm have not yet been established. This study aimed to use network analysis to inform an evidence-based definition of dual harm by assessing the relationship between self-harm and different forms of aggressive behaviour in young people (N = 3,579). We used data from the Avon Longitudinal Study of Parents and Children (ALSPAC). Results revealed low correlations between the variables, leading to sparse network models with weak connections. We found that when separated into their distinct forms, aggressive acts and self-harm are only weakly correlated. Our work provides preliminary evidence to assist in understanding and managing dual harm within clinical and forensic settings and informs recommendations for future research.

Perspectives on mathematics competitions and their relationship with mathematics education.

The nature of the area of mathematical competitions as a design science is considered, historical roots of mathematical problem-solving competitions are traced, the complementary aspects of mathematics as theory building and as problem solving are touched upon in relation to the practice of competitions. Two historical figures, Euler and Erdos, emerge, and the appropriateness of many of Euler's mathematical ventures are seen as role models for competition mathematics as first put into practice in mathematical competitions towards the end of the nineteenth century. Distinctions and definitions are made, a venture into identifying competition syllabi and the principal types of reasoning employed in solving competition problems is explored, and a description of the many different types of competitions is considered. Interaction between the field of mathematics itself and problem-solving competitions is briefly explored, as are the possibilities that open when competitions and their access to huge amounts of data, both national and international, are taken into account in research belonging to mathematics education. Finally, the range of topics addressed in this special issue of ZDM is covered, along with some possible conclusions relating to the components of the overview.

Commentary: Bringing together lived experience, clinical and research expertise - a commentary on the May 2022 debate (should CAMH professionals be diagnosing personality disorder in adolescence?).

BACKGROUND: There is a wealth of evidence to suggest that the Borderline Personality Disorder (BPD, or similar Emotionally Unstable Personality Disorder, EUPD) construct is harmful. We provide a commentary on the ideas expressed in the May Debate issue, highlighting both concerns and alternatives. METHOD: We bring together lived experience, clinical and research expertise. This commentary was written collaboratively drawing on all these sources of evidence. RESULTS: We outline evidence that the BPD construct is invalid, harmful, not necessary for effective treatment and a potential block to the development and evaluation of alternatives. CONCLUSIONS: We ask readers to consider these concerns, perspectives and ideas.

A systematic review of the relationship between momentary emotional states and nonsuicidal self-injurious thoughts and behaviours.

BACKGROUND: Nonsuicidal self-injury (NSSI) is associated with high levels of distress, co-morbid mental health issues, and elevated risk of suicide. Previous literature indicates that emotion regulation is the most endorsed function of NSSI. Experience Sampling Methodology (ESM) provides a powerful tool for investigating the moment-to-moment associations between emotional states and NSSI thoughts and behaviours. The aim of the current study was to systematically review and evaluate ESM research concerning the relationship between momentary emotional states and NSSI. METHODS: A systematic search of electronic databases from date of inception to 16th April 2021 was conducted. This was supplemented through backwards citation tracking. A risk of bias assessment was completed prior to data synthesis. RESULTS: Nineteen eligible studies were identified for inclusion in the review. Heightened negative affect was found to typically precede instances of NSSIT thoughts and behaviour. Results were less consistent for positive affect. LIMITATIONS: Sample sizes across studies were often small, meaningful effect sizes were not always reported, and non-validated measures of NSSI thoughts and behaviour were used during ESM assessments. CONCLUSIONS: The results support affect regulation models of NSSI, and demonstrate the value of ESM studies, specifically those sampling more than once per day, in plotting the temporal, "in-the-moment" characteristics of these processes.

The Co-occurrence of Self-Harm and Aggression: A Cognitive-Emotional Model of Dual-Harm.

There is growing evidence that some individuals engage in both self-harm and aggression during the course of their lifetime. The co-occurrence of self-harm and aggression is termed dual-harm. Individuals who engage in dual-harm may represent a high-risk group with unique characteristics and pattern of harmful behaviours. Nevertheless, there is an absence of clinical guidelines for the treatment and prevention of dual-harm and a lack of agreed theoretical framework that accounts for why people may engage in this behaviour. The present work aimed to address this gap in the literature by providing a narrative review of previous research of self-harm, aggression and dual-harm, and through doing so, presenting an evidence-based theory of dual-harm - the cognitive-emotional model of dual-harm. This model draws from previous studies and theories, including the General Aggression Model, diathesis-stress models and emotional dysregulation theories. The cognitive-emotional model highlights the potential distal, proximal and feedback processes of dual-harm, the role of personality style and the possible emotional regulation and interpersonal functions of this behaviour. In line with our theory, various clinical and research implications for dual-harm are suggested, including hypotheses to be tested by future studies.

Posttraumatic stress symptomology and non-suicidal self-injury: The role of intrusion and arousal symptoms.

BACKGROUND: Previous evidence has shown a strong relation between Posttraumatic Stress Disorder (PTSD) symptomology and Non-Suicidal Self-Injury (NSSI). The current study aimed to extend prior research by investigating the relationship between PTSD symptom clusters (arousal and intrusion) and NSSI, and putative moderators of this association within a large-scale adult sample in England. METHOD: A subsample of participants with experiences of trauma in adulthood (n = 2,480) from the Adult Psychiatric Morbidity Survey 2007 (APMS 2007) was utilised to examine the relations among PTSD intrusion and arousal symptom clusters, childhood interpersonal trauma, perceived social support and lifetime NSSI. RESULTS: Arousal symptoms were consistently associated with NSSI, even when adjusting for multiple covariates, and had a stronger relationship than intrusion symptoms. Childhood interpersonal trauma was independently and significantly associated with lifetime NSSI after adjusting for covariates. The moderating effects of childhood interpersonal trauma and perceived social support were not statistically significant. LIMITATIONS: The study was cross-sectional and utilised self-report assessments to measure PTSD, NSSI, and childhood interpersonal trauma. CONCLUSION: Findings support the role of PTSD arousal and childhood interpersonal trauma in relation to NSSI. The moderating role of childhood interpersonal trauma and perceived social support lacks supporting evidence. Findings highlight the need for NSSI screening as well as for specific interventions that target the complex needs of those who exhibit elevated PTSD arousal symptoms, especially those with a history of childhood interpersonal trauma.

Shame and the psychosis continuum: A systematic review of the literature.

OBJECTIVES: Shame is increasingly implicated in the development and maintenance of several psychological problems including psychosis. The aim of the current paper was to review the research literature concerning the relationship between shame and the psychosis continuum, examining the nature and direction of this relationship. METHOD: Systematic searches of databases PsycINFO, Medline, Scopus, and Web of Science (from the earliest available database date until November 2016) were undertaken to identify papers that examined the relationship between shame and psychosis or psychotic experiences. RESULTS: A total of 20 eligible papers were identified. Risk of bias assessment identified methodological shortcomings across the research in relation to small, unrepresentative samples and failure to control for confounding variables. Narrative synthesis suggested positive associations between shame and paranoia (n = 10, r = .29-.62), shame and psychosis (n = 1, r = .40), and shame and affiliation with voices (n = 1, ß = .26), and suggested that shame was greater in those with psychosis compared to controls (n = 4, d = 0.76-1.16). CONCLUSIONS: Overall, several studies provide partial support for the theory that shame is an important factor in relation to psychotic experiences in both clinical and non-clinical populations, particularly paranoia. However, the predominance of cross-sectional designs prevents any conclusions being drawn concerning the temporal nature of associations. Additional research is necessary to further delineate the role of shame in relation to specific psychotic experiences such as voice-hearing. Longitudinal research is particularly needed to help establish the directionality and temporal aspects of effects. PRACTITIONER POINTS: Research indicates moderate-to-strong positive associations between shame and psychotic experiences in the existing literature. The results provide preliminary evidence that shame may play a role in relation to psychosis and, more specifically, paranoia. Findings should be interpreted with caution due to many disparities across the studies reviewed and methodological shortcomings (e.g., small sample sizes). It is not currently possible to determine causality or direction of effect due to the cross-sectional design of all existing studies.

Psychological Correlates of Self-Harm within Gay, Lesbian and Bisexual UK University Students.

This study explores the association between lesbian, gay or bisexual (LGB) status and self-harm in UK higher education students. There is currently limited data on this association, and the role psychological variables have in potentially explaining this link, in UK students. We examine whether LGB status is associated with self-harm (both non-suicidal self-injury [NSSI] and suicide attempts [SA]), and whether 4 psychological variables (depression, anxiety, belongingness, self-esteem) mediate this association. A cross-sectional survey was used. UK university students (n = 707) completed an online survey including measures of self-harm, affective symptoms, belongingness, and self-esteem. Latent Variable Modelling (LVM) was used to test our hypotheses. LGB status remained associated with an elevated risk of NSSI and SA even after accounting for mediating factors. Self-esteem and (in the case of SA but not NSSI) thwarted belongingness, did, however, explain some of this association and were correlated with self-harm risk. The findings suggest that psychological factors may account for the association between LGB status and self-harm and, as such, prevention and intervention efforts directed at these psychological mediators may help to reduce self-harm risk in this population.

A Systematic Review of the Evidence Supporting Mobile- and Internet-Based Psychological Interventions For Self-Harm.

OBJECTIVES: Internet- and mobile phone-based psychological interventions have the potential to overcome many of the barriers associated with accessing traditional face-to-face therapy. Self-injurious thoughts and behaviors (STB) are prevalent global health problems that may benefit from Internet- and mobile-based interventions. We provide a systematic review and meta-analysis of studies evaluating mobile- and Internet-based interventions for STB, including nonsuicidal self-injury (NSSI). METHODS: Online databases (PsycINFO, Web of Science, Medline) were searched up to March 2019 for single-arm and controlled trials of Internet- or mobile-based interventions for STB. The potential for bias was assessed using the Cochrane risk of bias tool. RESULTS: Twenty-two eligible trials were identified. The research was limited by a lack of controlled designs and small samples. Evidence supports the acceptability of interventions. There is preliminary evidence that these interventions are associated with a decline in STB. A meta-analysis suggested a positive treatment effect on suicidal ideation when compared to treatment as usual, but not when trials with active controls were also considered. CONCLUSIONS: Overall, Internet- and mobile-based interventions show promise and further controlled trials are warranted, focusing on behavioral outcomes (NSSI, suicidal behavior). This review was preregistered with PROSPERO (CRD42017074065).

Shame, social deprivation, and the quality of the voice-hearing relationship.

OBJECTIVES: Many individuals hold different beliefs about the voices that they hear and have distinct relationships with them, the nature of which may determine the distress experienced. Understanding what factors contribute to these beliefs and relationships and consequently the resulting distress is important. The current research examined whether shame and social deprivation, in a sample of adult voice-hearers, were related to the relationships that individuals had with their voices or the beliefs that they held about them. DESIGN: The study utilized a cross-sectional, Internet-based design. METHODS: Eighty-seven adult voice-hearers from England were recruited to the online survey. Participants completed measures regarding shame, beliefs about voices, and relationships with voices and provided demographic information and postcodes that were used to refer to Index of Multiple Deprivation data. RESULTS: Social deprivation and shame were not associated. Shame was positively associated with variables describing negative voice-hearing beliefs/relationships but not positive voice-hearing beliefs/relationships. Principal component analysis on the eight voice-hearing variables yielded two components related to positive and negative voice-hearing qualities. A multiple regression conducted on the two components identified that shame was only associated with negative voice-hearing qualities. CONCLUSIONS: The results suggest that therapies that target shame may be helpful when working with negative voice-hearing beliefs and relationships. Future research should utilize experimental or longitudinal designs to examine the direction of the relationship. PRACTITIONER POINTS: The results contribute to the limited research evidence available regarding the relationship between shame and voice-hearing. The results suggest the utility of psychological therapies that focus on shame such as compassion-focused therapy and that conceptualize voices interpersonally such as cognitive analytic therapy. No conclusions can be made regarding causation. The sample size was relatively small, and results cannot be generalized to other areas of the United Kingdom. Future research should utilize experimental and longitudinal designs to examine the impact of shame on voice-hearing experiences and to examine other factors that may predict shame.

What is the relationship between rejection and self-harm or suicidality in adulthood?

BACKGROUND: Rejection is an adverse experience that may help explain the heightened risk of self-harm and suicide amongst many societal groups. The aim of this systematic review was to determine the relationship between rejection experiences and self-harm and suicidal ideation. METHOD: The databases PsychINFO, CINAHL, Medline and Web of Science were searched from inception until May 2017 using key search terms. Quantitative studies were included if they were; (i) mean sample age over 18; (ii) in the English language; (iii) and had a measure of self-harm or suicidal behaviour and a measure of rejection. The results were synthesised narratively. RESULTS: Eighteen studies were identified for the review. Fifteen out of the eighteen studies found a significant positive association between rejection and self-harm. This association was identified within several marginalised groups known to be at risk of self-harm, including those from lesbian, gay or bisexual sexuality or those who identify as transgender. LIMITATIONS: Heterogeneity between the measures of self-harm, suicidal behaviour and rejection, as well as the lack of longitudinal analyses made it difficult to draw firm conclusions. CONCLUSION: Perceived rejection may leave some individuals at risk of self-harm and might account for the elevated risk in marginalised societal groups. Interventions focused on modifying rejection experiences may help reduce the risk of self-harm in this population.

Attachment, mentalisation and expressed emotion in carers of people with long-term mental health difficulties.

BACKGROUND: Expressed emotion (EE) is a global index of familial emotional climate, which is comprised of emotional over-involvement (EOI) and critical comments (CC)/hostility. Although EE is an established predictor of negative outcomes for both people with long-term mental health difficulties and their family carers, its psychological underpinnings remain relatively poorly understood. This paper examined associations between attachment, mentalisation ability and aspects of EE. METHODS: Carers of people with long-term mental health difficulties (n = 106) completed measures of adult attachment (the Experiences in Close Relationships-Short Form questionnaire), mentalisation (the Reading the Mind in the Eyes Test and the Emotional Self-Efficacy Scale) and EE (the Family Questionnaire). Data were analysed using hierarchical multiple regression. RESULTS: Attachment avoidance and facets of mentalisation were directly and uniquely positively associated with CC/hostility, with attachment avoidance and other-directed emotional self-efficacy (one facet of mentalisation) each significantly predicting CC/hostility scores after controlling for the effects of EOI and demographic variables. However, no associations were observed between EOI, attachment anxiety and mentalisation. Furthermore, no indirect effects from attachment to EE via mentalisation was found. CONCLUSIONS: Although it would be premature to propose firm clinical implications based on these findings, data indicate that it may be beneficial for clinicians to consider attachment and mentalisation in their conceptualisation of carers' criticism and hostility. However, further research is needed to clarify the magnitude of these associations and their direction of effect before firm conclusions can be drawn.

This corrosion: A systematic review of the association between alternative subcultures and the risk of self-harm and suicide.

BACKGROUND: Rates of self-harm and suicide are increasing in young people. The literature suggests that individuals who identify with alternative subcultures (e.g., Goth) may be at a greater risk. OBJECTIVE: To explore the prevalence of self-harm and suicide in alternative subcultures and the factors that might contribute to this increased risk. METHOD: Using a systematic strategy, the databases PsycINFO, Scopus, MEDLINE and Web of Science, and the E-Thesis online service (ETHOS) were searched for English language only papers, with no restrictions in terms of date of publication. Papers were selected that included data on the relationship between either alternative subculture identity (e.g., Goth) or preference for alternative music (e.g., Heavy Metal) and self-harm or suicide. Ten quantitative papers were included: seven cross-sectional, two longitudinal and one cross-sectional state-level comparison study. Two qualitative papers were also included. Studies were assessed by two reviewers for risk of bias. RESULTS: The findings indicated that individuals who associated with alternative subcultures were at a greater risk of self-harm and suicide. Whilst qualitative papers identified potential mechanisms (e.g., exposure to self-harm and the way self-harm is presented or normalized), there remains limited support for these mechanisms. CONCLUSIONS: More research is required to understand the association between self-harm, suicide and alternative subculture affiliation, and the factors underlying it. Longitudinal studies and studies focusing on mechanism are particularly important. PRACTITIONER POINTS: The review supports the suggestion that those who identify as belonging to an alternative subculture may be at a higher risk of self-harm and suicidal behaviour. It also presents preliminary evidence that alternative affiliation predicts self-harm over time, and that this effect holds whilst adjusting for a number of likely confounders. The findings highlight the importance of increasing the awareness of the victimization and potential risk that these groups hold and suggests areas for intervention in health, educational, and social services. The review does not, however, indicate specifically what it is about alternative subculture affiliation (or alternative music preference) that could contribute to the risk of self-harm. Consequently, studies with a greater focus on mechanisms are needed. Methodological limitations (e.g., cross-sectional studies, small sample of 'alternative' participants, westernized samples) restricted the reliability and validity of the results which impacted on the extent to which the findings could be generalized more widely.

Self-esteem and non-suicidal self-injury in adulthood: A systematic review.

BACKGROUND: Non-suicidal self-injury (NSSI) is a self-destructive act that represents a considerable burden on the individual and society. Low self-esteem may be a psychological variable that is related to NSSI. However, little is known about the nature of this relationship in adulthood. This systematic review therefore aimed to provide a synthesis of the available literature on the relationship between self-esteem and NSSI. METHODS: Articles were independently identified and risk of bias assessed by two reviewers searching PsycINFO, CINAHL, Medline and Web of Science databases. Inclusion criteria were: (1) a mean sample age of eighteen years or over (2) full manuscripts available in English (3) assessment of NSSI (4) assessment(s) of self-esteem. A narrative synthesis of results was undertaken. A random-effects meta-analysis of differences in self-esteem between NSSI and non-NSSI groups was also undertaken. RESULTS: Seventeen studies were identified and indicated a significant negative relationship between self-esteem and NSSI. The meta-analysis indicated lower self-esteem in those with experiences of NSSI versus those without, d = 0.59 - 1.17. Results suggested that although low self-esteem and NSSI are related in both clinical and non-clinical populations, there are a number of factors which also influence this relationship. LIMITATIONS: The absence of longitudinal research is a major limitation of this literature. CONCLUSIONS: It will be important for clinicians to consider the impact of self-esteem in those seeking support for NSSI. Further research should undertake longitudinal research to better understand the self-esteem and NSSI relationship.

Guilt, shame and expressed emotion in carers of people with long-term mental health difficulties: A systematic review.

Expressed emotion (EE) is a global index of familial emotional climate, whose primary components are emotional over-involvement (EOI) and critical comments (CC)/hostility. There is a strong theoretical rationale for hypothesising that carers' guilt and shame may be differentially associated with their EOI and CC/hostility respectively. This systematic review investigates the magnitude of these theorised associations in carers of people with long-term mental health difficulties. Electronic searches (conducted in May 2016 across Medline, CINAHL, Embase, PsycINFO and ProQuest) were supplemented with iterative hand searches. Ten papers, reporting data from eight studies, were included. Risk of bias was assessed using a standardised checklist. Relevant data were extracted and synthesised narratively. EOI was positively associated with both guilt and shame, whereas CC/hostility was positively associated with shame. The strength of associations varied depending on whether or not guilt and shame were assessed within the context of the caring relationship. Based on these data, an argument can be made for the refinement, development and evaluation of systemic and individual interventions designed to target carers' guilt and shame. However, more research is needed to clarify the strength of these associations and their direction of effect before firm conclusions can be drawn.

Out of the blue: Untangling the association between impulsivity and planning in self-harm.

BACKGROUND: Planned and unplanned acts of self-harm may have distinct clinical and psychological correlates. Trait impulsivity is one factor that might be expected to determine whether self-harm is planned. Research so far has focussed on suicide attempts and little is known about how individuals engaging in planned and unplanned acts of self-harm differ. The aim of the current study was to examine how individuals who report planned self-harm, unplanned self-harm, and no self-harm differ in terms of impulsivity and affective symptoms (depression, anxiety, and activated mood). METHOD: An online survey of University students (n = 1350) was undertaken including measures of impulsivity, affective symptoms and self-harm. Analyses made use of a multinomial logistic regression model with affective and cognitive forms of impulsivity estimated as latent variables. RESULTS: Trait affective impulsivity, but not cognitive, was a general risk factor for whether self-harm occurred. There was no evidence of differences between planned and unplanned self-harm. Affective symptoms of depression and anxiety mediated the relationship between affective impulsivity and self-harm. LIMITATIONS: The study was cross-sectional, relied on a student sample which may not generalise to other populations. CONCLUSIONS: Trait affective impulsivity is associated with self-harm but it appears to be mediated by depression and anxiety symptoms. The exact relationships between trait affective impulsivity, depression, anxiety and self-harm require further longitudinal research in clinical populations but might lead to improved risk assessment and new therapeutic approaches to self-harm.

A model of suicidal behavior in posttraumatic stress disorder (PTSD): the mediating role of defeat and entrapment.

The aim of this study was to examine whether depression, hopelessness and perceptions of defeat and entrapment mediated the effects of posttraumatic stress disorder (PTSD) symptoms on suicidal behavior. Participants were 73 individuals (mean age=29.2, S.D.=10.9, 79.5% female) diagnosed with current or lifetime PTSD who reported at least one PTSD symptom in the past month. Participants completed a series of self-report measures assessing depression, hopelessness and perceptions of defeat and entrapment. The Clinician Administrated Posttraumatic Scale for DSM-IV was administered to assess the presence and severity of PTSD symptoms. The results of Structural Equation Modeling supported a model whereby perceptions of defeat and entrapment fully mediated the effects of PTSD symptom severity upon suicidal behavior. The finding that perceptions of defeat and entrapment mediate the relationship between PTSD symptom severity and suicidal behavior was replicated in a subgroup of participants (n=50) who met the full criteria for a current PTSD diagnosis. The results support a recent theoretical model of suicide (The Schematic Appraisal Model of Suicide) which argues that perceptions of defeat and entrapment have a key role in the development of suicidal behaviors. We discuss the clinical implications of the findings.