Non-suicidal self-injury and frequency of suicide attempts: The role of pain persistence

Can clinician's risk assessments distinguish those who disclose suicidal ideation from those who attempt suicide?

Participants were 85 individuals who made suicide attempts within two years of their Improving Access to Psychological Therapies (IAPT) assessment, identified using record linkage. Two comparison groups, non-suicidal controls (n = 1416) and (ideators, n = 743) were compared on variables extracted from the standardized IAPT risk assessment interview. Disclosure of a historical suicide attempt or non-suicidal self-injury (NSSI) distinguished those making an attempt from those with suicidal ideation only, but suicidal intent did not. A third of the participants concealed a historical suicide attempt. The IAPT Phobia Scale classified 49.30% of attempters with 100% specificity. The IAPT Phobia Scale may have clinical value in assessing risk but requires validation. Past suicide attempt and NSSI have better clinical risk assessment utility than current suicidal ideation intensity. Risk assessment relying on disclosure is likely to be flawed and risks support being withheld from those assumed to be at lower risk.

Pain tolerance and threshold in suicide attempters: A systematic review and meta-analysis

It has been hypothesized that individuals less sensitive to pain could be at higher risk of suicide. However, data on pain sensitivity in suicide attempters (SA) obtained using experimental procedures are heterogeneous. The aim of this systematic review and meta-analysis was to investigate and compare pain tolerance and threshold in SA (patients with lifetime history of suicide attempt), non-attempters (psychiatric controls, PC), and healthy controls (HC). A random effects meta-analysis was used to estimate the standardized mean differences using data from 16 studies that compared physical pain tolerance and threshold in SA and PC or HC. Pain tolerance and threshold were not significantly different in SA and PC. However, pain tolerance, but not threshold, was higher in SA than HC. Our findings do not support the hypothesis of an altered pain perception related as a trait for suicidal vulnerability, but rather suggest altered pain perception related to psychiatric vulnerability.

Decreased gray matter volume in regions associated with affective pain processing in unmedicated individuals with nonsuicidal self-injury

Nonsuicidal self-injury (NSSI) has been consistently associated with a reduced aversion to physical pain. Yet, little research has been done to investigate the brain structures related to pain in individuals with NSSI. This study examined gray matter volume patterns of pain processing regions in participants engaging in NSSI (n = 63) and age-, sex-, and handedness-matched healthy controls (n = 63). Voxel-based morphometry was performed to explore gray matter volume in regions of interest (ROIs) and partial correlation analyses were conducted to identify their associations with the frequency, versatility, duration, functions, and pain intensity of self-injury. As a result, significant volume decreases were found in the right anterior insula, bilateral secondary somatosensory cortex (SII), and left inferior frontal gyrus. Moreover, individuals with smaller anterior insula and SII volume showed a higher likelihood of endorsing affect-regulation and sensation-seeking functions of NSSI, as well as engaging in self-injury with a greater perceived intensity of pain. Our results provide the first empirical evidence that individuals with NSSI may exhibit distinct characteristics in brain regions associated with the affective component of pain processing. These neurobiological changes may be associated with their maladaptive response to noxious and painful NSSI experiences.

For Better or Worse?: The role of cognitive flexibility in the association between nonsuicidal self-injury and suicide attempt

Nonsuicidal self-injury (NSSI) has been repeatedly associated with increased suicide risk. However, the transition from NSSI to suicidal thoughts and behaviors still remains as an enigma. One possible construct that may influence this relationship is cognitive flexibility, which refers to the ability to adapt responses/strategies based on environmental feedback. It may be that greater cognitive flexibility increases one's cognitive accessibility to suicide, making it a more viable option upon distress especially for those with a prior history of NSSI. Conversely, it may be that less cognitive flexibility creates a negative bias that exacerbates the effects of NSSI on suicide. Thus, in this study, we examined how NSSI characteristics (i.e., frequency and methods) interact with cognitive flexibility to predict lifetime suicide attempt (SA) history. Participants were 505 individuals with a lifetime history of NSSI who completed a survey assessing for their NSSI experiences, cognitive flexibility, and SA history. Moderation analyses were conducted while controlling for sexual orientation, which significantly predicted SA history. Results indicated a significant interaction between number of NSSI methods endorsed and cognitive flexibility. In particular, individuals were more likely to have had a history of SA if they scored higher on the alternative subscale of cognitive flexibility. The results suggest that the adaptive value of cognitive flexibility may be context dependent, and highlight the importance of personalized care among those who engage in self-harm.

Suicide capability within the ideation-to-action framework: A systematic scoping review

Suicide capability is theorised to facilitate the movement from suicidal ideation to suicide attempt. Three types of contributors are posited to comprise suicide capability: acquired, dispositional, and practical. Despite suicide capability being critical in the movement from ideation-to-attempt, there has been no systematic synthesis of empirical evidence relating to suicide capability that would enable further development and refinement of the concept. This study sought to address this synthesis gap. A scoping review was conducted on suicide capability studies published January 2005 to January 2022. Eleven electronic databases and grey literature sources were searched returning 5,212 potential studies. After exclusion criteria application, 90 studies were included for final analysis. Results synthesis followed a textual narrative approach allocating studies based on contributors of suicide capability. Most studies focused on investigating only one factor within contributors. Painful and provocative events appear to contribute to acquired capability more so than fearlessness about death. Whilst emerging evidence for dispositional and practical contributors is promising, the small number of studies prevents further conclusions from being drawn. An unexpected additional cognitive contributor was identified. The focus of a single factor from most studies and the limited number of studies on contributors other than acquired capability limits the theoretical development and practical application of suicide capability knowledge. Given that suicide is a complex and multifaceted behaviour, future research that incorporates a combination of contributors is more likely to advance our understandings of suicide capability.

What distinguishes high and low-lethality suicide attempts in older adults? A systematic review and meta-analysis

Those making suicide attempts with highly lethal medical consequences are arguably the best proxy for those who die by suicide and represent a qualitatively different population from those making lower lethality attempts. Different factors influence the likelihood of a suicide attempt occurring and the lethality of that attempt. Both are important dimensions of risk. Older adults represent a distinct group in suicide research with unique risk factors that influence the lethality of their suicide attempts. This systematic review and meta-analysis summarises factors distinguishing those making high and low-lethality suicide attempts in older adulthood. Databases PsycINFO, PubMed (MEDLINE), Embase and CINAHL were systematically searched with seven of 1182 unique records included. Random effects meta-analyses were conducted on 18 variables in addition to a narrative synthesis regarding executive function. Only increased suicidal intent and planning meaningfully distinguished high from low-lethality attempters in meta-analyses. A large effect size was additionally observed for white ethnicity. Diminished alcohol use disorder prevalence and depression severity, and greater cognitive impairment, may be associated with high lethality attempters but further research is needed. Age and gender were not associated with lethality, contrary to adult populations. A narrative synthesis of studies exploring differences in executive functioning suggested high-lethality attempters were less likely to impulsively act on suicidal urges, allowing them to better plan suicide attempts that are more lethal, and are less likely to alter suicidal plans. Key limitations were that meta-analyses were underpowered to detect small effect sizes, and samples were largely white and limited to the USA.

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.

Testing Whether Suicide Capability Has a Dynamic Propensity: The Role of Affect and Arousal on Momentary Fluctuations in Suicide Capability

To prevent suicidal behaviors, it is crucial to understand the mechanisms and processes that enable an individual to act on suicidal thoughts. Suicide capability, which involves an increased pain tolerance and fearlessness of death, is a critical factor that enables an individual to endure the physical pain necessary to make a lethal suicide attempt. Extant research has largely conceptualized suicide capability as developing linearly in response to painful and provocative experiences, but the emerging literature on the temporal dynamics of suicide has been challenging the notion of linearity in suicide risk. Few studies have directly measured and compared changes in suicide capability in response to rumination on different affective states. We sought to experimentally test if rumination in the context of low vs. high arousal emotions will prompt distinct changes in two core components of suicide capability: pain tolerance and fearlessness of death on two undergraduate student samples. In both studies, participants provided measures of subjective emotional state as well as pain threshold, tolerance, and persistence before and after completing experimental manipulations which included both emotion and rumination induction procedures. In the second study, measures of fearlessness about death and physiological arousal (heart rate) were added to the experimental procedures. We found significant decreases in pain threshold, tolerance, and persistence following the experimental manipulations but found no main effects of rumination or suicide risk. These findings suggest that suicide capability can fluctuate but these changes may occur through a different mechanism and/or differ between individuals at varying levels of suicide risk.

Predicting pain: differential pain thresholds during self-induced, externally induced, and imagined self-induced pressure pain

Supplemental Digital Content is Available in the Text.

Imagining pressure pain to be self-induced led to increased pressure pain thresholds. Such sensory attenuation of pain was also seen in actual self-induced pressure.

During self-induced pain, a copy of the motor information from the body's own movement may help predict the painful sensation and cause downregulation of pain. This phenomenon, called sensory attenuation, enables the distinction between self-produced stimuli vs stimuli produced by others. Sensory attenuation has been shown to occur also during imagined self-produced movements, but this has not been investigated for painful sensations. In the current study, the pressure pain thresholds of 40 healthy participants aged 18 to 35 years were assessed when pain was induced by the experimenter (other), by themselves (self), or by the experimenter while imagining the pressure to be self-induced (imagery). The pressure pain was induced on the participants left lower thigh (quadriceps femoris) using a handheld algometer. Significant differences were found between all conditions: other and self (P < 0.001), other and imagery (P < 0.001), and self and imagery (P = 0.004). The mean pressure pain threshold for other was 521.49 kPa (SE = 38.48), for self 729.57 kPa (SE = 32.32), and for imagery 618.88 kPa (SE = 26.67). Thus, sensory attenuation did occur both in the self condition and the imagery condition. The results of this study may have clinical relevance for understanding the mechanisms involved in the elevated pain thresholds seen in patients with self-injury behavior and the low pain thresholds seen in patients with chronic pain conditions. Imagery of sensory attenuation might also be used to alleviate the pain experience for patients undergoing procedural pain.

Assessing Physical Pain Perception and Psychological Distress Tolerance through the MMPI-2-RF: A Comparison of Multimethod Measures

While transdiagnostic factors are important domains in clinical assessment and treatment, there is little research to link such constructs to widely accepted and utilized broadband assessments such as the Minnesota Multiphasic Personality Inventory, 2nd edition - Restructured Form (MMPI-2-RF). A handful of studies suggest the ability of the MMPI-2-RF scales to capture variance in transdiagnostic constructs; however, this literature relies solely on self-report criterion measures, despite evidence that self-report and behaviorally-indexed correlates of psychopathology may measure varied aspects of the intended construct and can often yield differing results. The current study investigated MMPI-2-RF scales' ability to assess two widely examined transdiagnostic constructs, distress tolerance and pain perception, across both self-report and behavioral indicators. The sample included 115 undergraduate students who completed a valid MMPI-2-RF and multimethod measures of pain perception and distress tolerance. The results aligned with prior research in areas of internalizing symptoms, psychopathy, and suicide risk factors in self-report, but not behaviorally-based, assessment. Implications of this inconsistency, the association between clinical assessment and transdiagnostic constructs, and the heterogeneity of the distress tolerance and pain perception constructs are discussed.

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.

Expanding our understanding of the relationship between nonsuicidal self-injury and suicide attempts: The roles of emotion regulation self-efficacy and the acquired capability for suicide

OBJECTIVE

Although past literature has emphasized the role of acquired capability in the relationship between nonsuicidal self-injury (NSSI) and suicide attempts, support for the indirect relationship of NSSI to suicide attempts through acquired capability is limited. Thus, research examining other factors that may underlie this relationship is needed. Across two studies, this research examined the indirect relationships of NSSI frequency to suicide attempts through both acquired capability and emotion regulation self-efficacy (ERSE).

METHOD

Two large samples of adults (one nationwide community sample and one clinical sample of patients with substance use disorders) completed questionnaires and/or interviews.

RESULTS

Results revealed significant indirect relationships of NSSI frequency to lifetime suicide attempts through ERSE, but not acquired capability, within both samples.

CONCLUSIONS

Results highlight the relevance of ERSE to both suicide attempts and the NSSI-suicide attempt relationship, and suggest the potential utility of interventions aimed at increasing ERSE among individuals with repeated NSSI.

Interactive Effects of Acute Suicidal Affective Disturbance and Pain Persistence on Suicide Attempt Frequency and Lethality

Abstract. Background: Acute suicidal affective disturbance (ASAD) has been proposed as a suicide-specific entity that confers risk for imminent suicidal behavior. Preliminary evidence suggests that ASAD is associated with suicidal behavior beyond a number of factors; however, no study to date has examined potential moderating variables.  Aims: The present study tested the hypotheses that physical pain persistence would moderate the relationship between ASAD and (1) lifetime suicide attempts and (2) attempt lethality. Method: Students ( N = 167) with a history of suicidality completed self-report measures assessing the lifetime worst-point ASAD episode and the presence of a lifetime suicide attempt, a clinical interview about attempt lethality, and a physical pain tolerance task. Results: Physical pain persistence was a significant moderator of the association between ASAD and lifetime suicide attempts ( B = 0.00001, SE = 0.000004, p = .032), such that the relationship between ASAD and suicide attempts strengthened at increasing levels of pain persistence. The interaction between ASAD and pain persistence in relation to attempt lethality was nonsignificant ( B = 0.000004, SE = 0.00001, p = .765). Limitations: This study included a cross-sectional/retrospective analysis of worst-point ASAD symptoms, current physical pain perception, and lifetime suicide attempts. Conclusion: ASAD may confer risk for suicidal behavior most strongly at higher levels of pain persistence, whereas ASAD and pain perception do not influence attempt lethality.

Use of puppets to teach resourcefulness skills to women who self-injure: An exploratory study

BACKGROUND

Self-injurious behavior (SIB), when frequent and repetitive, can lead to risk behaviors resulting in accidental or intentional suicide. Psychoeducation about resourcefulness can be critical to interrupt the cycle of self-injury. Therapeutic puppetry provides a safe and secure vehicle for expressing feelings without fear of retaliation.

OBJECTIVES

Determine the outcome of a resourcefulness psychoeducation program, utilizing hand puppets as a teaching tool, on the measure of resourcefulness for adult women who self-injure.

METHODS

A psychoeducation program, utilizing hand puppets as a teaching tool, was offered to women during psychiatric hospitalization. Participants completed the Resourcefulness Scale (RS) pre and post intervention. A program evaluation to determine the effectiveness of hand puppets was completed. Acceptability and feasibility of the program was evaluated.

RESULTS

Sixteen participants completed the program. Results showed a statistically insignificant increase in scores. The program evaluation revealed agreement that resourcefulness learning was accomplished. Participants reported that hand puppets were helpful in practicing resourcefulness skills. Majority of participants recommended continuation of the program.

Do suicide attempters and suicide ideators differ in capability for suicide?

Suicide ideation is a prerequisite for suicide attempts. However, the majority of ideators will never act on their thoughts. It is therefore crucial to understand what differentiates those who consider suicide from those who attempt suicide. The aim of this study was to investigate the role of different aspects of capability for suicide (fearlessness about death, subjective pain tolerance, objective pain persistence) in differentiating suicide ideators from suicide attempters, single attempters from multiple attempters and recent attempters from distant attempters. A total of 308 psychiatric inpatients (53.6% female; age: M=36.92, SD=14.30) suffering from suicide ideation with or without lifetime suicide attempts were compared regarding fearlessness about death, subjective pain tolerance and objective pain persistence (assessed with a pressure algometer). No differences in fearlessness about death, subjective pain tolerance and objective pain persistence were found in suicide ideators vs. attempters, single vs. multiple attempters and recent vs. distant attempters. It might be presumed that fearlessness about death, subjective pain tolerance and objective pain persistence do not offer useful information for the differentiation between suicide ideators and attempters, however, there are several limitations to take into account. Further effort is needed to understand more clearly what differentiates suicide ideators from suicide attempters.

From ideation to action: recent advances in understanding suicide capability

Suicide capability is one of few risk factors associated with suicide attempts among ideators. In the decade since the Interpersonal Psychological Theory of Suicide introduced the concept of acquired capability (i.e. the ability to face the fear and pain associated with death), understanding of the capability to attempt suicide has grown. Acquired (e.g. NSSI), dispositional (e.g. genetic), and practical contributors (e.g. access to firearms) appear to influence suicide capability via mechanisms such as the fear of death, persistence through pain, and familiarity with suicide methods. Self-report methods have shown mixed results, highlighting the importance of developing behavioral measures of suicide capability.