The german version of the painful and provocative events scale: a psychometric investigation

Potential Mechanisms Underlying Suicidality in Autistic People with Attention Deficit/Hyperactivity Disorder: Testing Hypotheses from the Interpersonal Theory of Suicide

Background

Autistic people with co-occurring attention deficit/hyperactivity disorder (ADHD) appear to be at heightened risk of suicide. To understand why, we explored two explanatory mechanisms from the interpersonal theory of suicide: first, that co-occurring ADHD might be associated with greater risk through greater thwarted belongingness and perceived burdensomeness and, secondly, that hyperactive/impulsive features might incur additional risk through their association with painful and provocative events, which are suggested to create "capability" for suicide.

Methods

Autistic adults (n = 314) completed an online survey including measures of thwarted belongingness, perceived burdensomeness, painful and provocative events, acquired capability for suicide, and ADHD features. Creating an overall index of likely ADHD, we examined associations between likely ADHD, suicide ideation, and lifetime suicide attempts through the parallel mediators of thwarted belongingness, perceived burdensomeness, anxiety, and depression. In several models, we then examined hyperactive, impulsive, and inattentive features as predictors of exposure to painful and provocative events and subsequent capability for suicide, and examined whether these two variables, sequentially or individually, mediated an association with lifetime suicide attempts.

Results

Likely ADHD was associated with past-year suicide ideation through greater depression and perceived burdensomeness, which also mediated its association with more suicide attempts. Hyperactive and impulsive features were associated with exposure to painful and provocative events and through this acquired suicide capability. Both features were associated with more numerous suicide attempts through these two mediators sequentially, and through exposure to painful and provocative events alone.

Conclusions

These data suggest that suicidality in autistic people with ADHD may be partially related to perceived burdensomeness and to acquired suicide capability after exposure to painful and provocative events. However, as we observed a pathway to suicidality associated with painful and provocative events alone, it is likely that there are also other explanatory mechanisms for the influence of traumatic events on suicide risk.

An analysis of the Painful and Provocative Events Scale: Some painful and provocative findings

This research investigated the latent structure and correlates of the 26-item Painful and Provocative Events Scale (PPES). For a sample of 290 community respondents, results from parallel analysis indicated a 5-factor structure. Based on principal axis factoring with varimax rotation, scales of Intense physicality, Physical and mental trauma, Physical risk taking, Psychopathy, and Body enhancement were constructed, and these demonstrated a pattern of convergent and discriminant correlations with suicide-associated and demographic variables that supported the delineation of these scales as being distinct. In general, results challenge the current scoring of the PPES and, with developed scales being differentially related to demographic variables, indicate that both respondent age and sex require consideration for scale score interpretation.

The UPPS Model of Impulsivity and Suicide: A Systematic Literature Review

INTRODUCTION

Suicide is a leading cause of death worldwide. Although inconsistent, impulsivity has been identified as a risk factor for suicidal thoughts and behaviors, and these inconsistent findings can largely be attributed to varying operationalizations of impulsivity. As such, the UPPS model of impulsivity provides a clear definition of impulsivity and its associated features that may provide utility in clarifying unreliable findings between impulsivity and suicide. This review aimed to summarize relevant information pertaining to the UPPS model of impulsivity and suicide.

METHODS

This systematic review followed the a priori guide outlined by the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. Articles were gathered from PsycINFO, PsycArticles, Scopus, and PubMed.

RESULTS

Twenty-eight articles were reviewed and analyzed. Most articles reviewed reported on indirect (i.e., through mediators and moderators) associations between the UPPS dimensions and suicidal behaviors. Additionally, results noted limited between-group differences in UPPS facets among individuals with a history of suicide attempts and those without a history of suicide attempts, those with a history of suicide attempts and individuals with suicide ideation, and those with suicide ideation and those without suicide ideation, with the exception of lack of premeditation.

DISCUSSION

The results of this review indicate support for the UPPS model of impulsivity as a theoretical starting point when examining the relation between impulsivity and suicide. Further, findings are helpful for clinicians and case conceptualization. Particularly, suicide risk assessment and treatment would be impacted based on impulsivity traits and suicide history.

The Frequency and Subjective Impact of Painful and Provocative Events on the Acquired Capability for Suicide

BACKGROUND

Leading theoretical explanations for suicide state that for suicide death to occur, a person must have sufficient capability to enact an attempt. Exposure to painful and provocative events is hypothesized to play an important role in acquiring the capability for suicide over a lifetime. Unfortunately, assessment tools for painful and provocative events have focused solely on the frequency of events, neglecting the potential contributions of perceived impact. Further, past measurements have used predetermined items for painful and provocative events thereby neglecting other relevant events. The current study uses visual analog scales (VAS) to assess both the frequency and impact of painful and provocative events and how these contribute to the capability for suicide.

METHOD

Data were collected from 787 adults via Amazon's online platform.

RESULTS

Findings indicated that the frequency VAS and impact VAS both had a moderate correlation with the original Painful and Provocative Events Scale. Greater scores on the frequency VAS were associated with increased capability, whereas lower scores on the subjective impact VAS were associated with increased capability scores. Both VAS independently predicted capability above and beyond the PPES.

LIMITATIONS

Temporal or causal associations are unable to be drawn due to cross-sectional data. In addition, the sample was largely homogenous (White = 72%, female = 63.5%), limiting generalizability.

CONCLUSIONS

These initial findings demonstrate individuals who perceive painful and provocative events as being less impactful may have increased capability, and that VAS may be appropriate to approximate the impact and frequency of painful and provocative events.

No game, more pain - Examining possible long term effects and underlying mechanisms of habitual violent video gaming on the acquired capability for suicide

According to Joiner`s interpersonal-psychological theory of suicide repeated engagement in suicidal behavior or so-called painful and provocative events constitutes the acquired capability for suicide (ACS) comprising two facets: enhanced pain tolerance and fearlessness about death (FAD). Recent research showed that single bouts of violent-video-gaming (VVG) increase pain tolerance. It is unknown whether individuals who habitually play VVGs at a high frequency rate show higher signs of ACS in terms of low pain sensitivity, high tolerance and lowered FAD compared to non-gamers. In a cross-sectional case-control study, we compared pain sensitivity and tolerance during a 5-min Cold-Pressor-Test (CPT) besides FAD in young males, playing VVGs highly frequent (n = 18) vs. non-gamers (n = 17). Mood was rated before and after the CPT. We found higher CPT-pain tolerance, lower intensity ratings and higher FAD scores among gamers compared to non-gamers. A significant time x group interaction of pain ratings indicated a process of habituation in the gamers. An increase of positive mood in the gamers emphasizes the role of opponent processes. The results suggest that habitual VVG might reflect a repetitive behavior enhancing the ACS.

Exploring the scope and structure of suicide capability

OBJECTIVE

Recent theories of suicide suggest that a construct called "capability for suicide" facilitates the progression from suicidal thoughts to attempts. Various measures of capability have been developed to assess different parts of the construct, but studies report inconsistent findings regarding reliability, validity, and structure. The present study pooled items from multiple measures to identify distinct, reliable, and valid domains of suicide capability.

METHOD

We administered items from several suicide capability measures to an online sample of US adults (n = 387), and utilized exploratory factor analysis to identify distinct domains of capability. We then examined the internal consistencies of and intercorrelations among these domains, as well as their associations with suicide attempts.

RESULTS

Findings identified three domains of suicide capability: fearlessness about death, practical capability, and pain tolerance. These domains were internally consistent (αs = 0.80-0.92), and relatively independent from one another (intercorrelations = 0.15-0.35). Finally, each of these domains was moderately elevated among attempters compared to ideators (although only fearlessness about death and practical capability offered unique information about attempter status).

CONCLUSIONS

Findings suggest that fearlessness about death, practical capability, and pain tolerance can be measured reliably, and may be relevant for understanding which ideators make attempts.

The role of the 5-HTTLPR polymorphism in acquired capability for suicide

OBJECTIVE

According to the Interpersonal Psychological Theory of Suicide, capability for suicide comprises two dimensions: fearlessness about death and elevated pain tolerance. The short (S) allelic variant of the serotonin transporter gene-linked polymorphic region (5-HTTLPR) has repeatedly been associated with more violent and lethal suicide methods and lethality of suicide attempts. The current study aimed to investigate whether 5-HTTLPR allelic variants are associated with fearlessness about death and pain tolerance/persistence and whether it moderates the relationship between childhood maltreatment and acquired capability for suicide.

METHOD

A cohort of 208 inpatients hospitalized due to a recent suicide attempt or severe suicidal ideation was genotyped for the 5-HTTLPR and assessed for childhood maltreatment. Subjective pain tolerance and fearlessness about death as well as objective pain persistence was assessed using a pressure algometer.

RESULTS

Fearlessness about death, pain tolerance, and pain persistence did not differ between 5-HTTLPR genotypes. However, there was a significant correlation between self-reported childhood maltreatment and fearlessness about death that emerged exclusively in homozygous S-allele carriers.

CONCLUSION

Results suggest that there are no "high-risk"-alleles that generally increase capability for suicide. However, in terms of future suicide-related behaviors exposure to childhood maltreatment events could exert a particularly negative influence on homozygous S-allele carriers by increasing their fearlessness about death.

Validation of the German capability for suicide questionnaire (GCSQ) in a high-risk sample of suicidal inpatients

BACKGROUND

The German Capability for Suicide Questionnaire (GCSQ) was developed to measure fearlessness of death and pain tolerance - two constructs central to the Interpersonal Theory of Suicide. Initial scale development, definition of the factor structure and confirmation of the two-dimensional factor structure was performed in samples suffering from relatively low levels of suicide ideation/behavior. The present study aimed to validate the German Capability for Suicide Questionnaire (GCSQ) in a high-risk sample of suicidal inpatients.

METHODS

Factor structure, reliability and validity were investigated in a sample of inpatients (N = 296; 53.0% female; age in years: M = 36.81, SD = 14.27) admitted to a hospital due to a recent suicide attempt or an acute suicidal crisis (in immediate need of inpatient treatment). To establish convergent validity, interview-based assessments of lifetime suicide attempts and non-suicidal self-injury as well as questionnaire-based assessments of painful and provocative events were used. Finally, stability of GCSQ-scores over a follow-up period of 12 months was assessed.

RESULTS

Results indicated good psychometric properties, and provided additional evidence for construct validity and stability of the subscales over a one-year period, and demonstrated adequate fit of the data with respect to the original factor structure.

CONCLUSIONS

Results suggest that the GCSQ is a brief, reliable, and valid measure of capability for suicide that can be used in clinic assessment and research.

Validation of a Chinese Version of the Acquired Capability for Suicide Scale

This study aimed to revise and validate a Chinese Version of the Acquired Capability for Suicide Scale (ACSS-CV). In study 1 of 395 Chinese college students, a two-factor model comprising fearlessness about death and pain tolerance achieved satisfactory model fit. In study 2 of 491 different students, the ACSS-CV had good internal consistency, test-retest reliability, convergent validity, and discriminant validity. The ACSS-CV may be considered a useful instrument for measuring the acquired capability for suicide in Chinese college students.

Establishing the psychometric properties and construct validity of the Painful and Provocative Events Scale-Revised

BACKGROUND

Engagement in painful and provocative events is central to hypotheses for how capability for suicide develops. However, the existing measure of painful and provocative events is not psychometrically sound. We developed a measure with improved psychometric properties: the Painful and Provocative Events Scale (PPES)-Revised.

METHOD

In study 1, 447 adults (53.5% women, mean age = 35.4 years) answered 77 items describing painful and/or provocative experiences. Exploratory factor analysis (EFA) was performed. In study 2, 403 adults (55.1% women, mean age = 38.1 years) answered the retained items and confirmatory factor analysis (CFA) was performed. The scale's factorial invariance across gender was examined. Estimates of convergent and discriminant validity were obtained.

RESULTS

EFA yielded a two-factor structure, which was confirmed with CFA. The factor structure was invariant across men and women. Estimates of convergent and discriminant validity were promising.

LIMITATIONS

Limitations include non-weighted items, additional need for CFA among high-risk groups, lack of assessment of person-specific painful and provocative events, and need for prospective research to establish the scale's predictive validity.

CONCLUSIONS

By assessing painful and provocative events more uniformly and reliably than the existing measure, the PPES-Revised has the potential to advance the understanding of capability for suicide.

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.

Differentiating Suicide Attempters from Suicide Ideators: The Role of Capability for Suicide

This study examined whether different components of capability for suicide (i.e., fearlessness about death, pain tolerance, pain insensitivity, preparation for suicide, suicide plan, and courage), as well as painful and provocative events, nonsuicidal self-injury, depressive symptoms, and hopelessness, could distinguish between suicide attempters, suicide ideators, and non-suicidal controls. A total of 930 Chinese adolescents completed questionnaires, and a multinomial logistic regression was conducted to identify factors that could distinguish among the 3 groups. We found that higher levels of pain tolerance, more detailed suicide plans, more positive attitudes towards suicide, as well as more painful and provocative experiences and more severe depressive symptoms were positively associated with increased likelihood of the engagement in both suicide ideation and suicide attempts. Only nonsuicidal self-injury increased the likelihood of falling in the suicide attempt group as compared to the suicide ideation group. Findings of this study emphasize the role of nonsuicidal self-injury in intervening suicidality.

Non-monotonic temporal variation in fearlessness about death: A latent class growth analysis

According to the Interpersonal-Psychological Theory of Suicide, fearlessness about death is proposed to increase monotonically (i.e., either increasing or remaining stable) and thus, not be amenable to intervention; however, this assumption has not been explicitly tested. We utilized latent class growth modeling to examine the trajectory of this construct over a brief interval (i.e., data collected every three days over a 15-day time period) among college students (N = 716), and found evidence that fearlessness does not monotonically increase. Specifically, our analyses revealed three classes, each with distinct trajectories over time: a High/Increasing class (i.e., high intercept, significantly increasing slope), Average/Stable class (i.e., average intercept, flat and non-significant slope), and Low/Decreasing class (i.e., low intercept, significantly decreasing slope). The emergence of a Low/Decreasing group is in contrast to the assertion that fearlessness cannot decrease over time. Exploratory results also indicated that lifetime exposure to certain events (e.g., abuse, injury) was associated with membership in the Low/Decreasing class, suggesting that some individuals may be responding differently to painful and/or fear-inducing stimuli than the IPTS predicts. Our findings contradict the current conceptualization of fearlessness about death, and suggest instead that this construct fluctuates upward and downward over a brief interval.

A Psychometric Investigation of the Painful and Provocative Events Scale: Moving Forward

Acquired capability for suicide is posited to develop through repeated exposure to physically painful and psychologically provocative events; however, there is limited research evaluating the assessment of painful and provocative events. The current study examined the factor structure, validity, and reliability of the Painful and Provocative Events Scale (PPES). Categorical exploratory and confirmatory factor analyses were conducted in a sample of undergraduate students (N = 732). A 15-item PPES with a 3-factor solution best fits the data; however, both the subscales derived from factor analyses yielded inconsistent validity and reliability. Despite addressing limitations of previous psychometric investigations of the PPES, the inconsistent findings of the current study suggest the theoretical reconceptualization of painful and provocative events and the subsequent development of a valid and reliable assessment of painful and provocative events is needed to take the place of current versions of the PPES.

The application of the interpersonal-psychological theory of suicide to a sample of Swiss patients attending a psychiatric emergency department for a non-lethal suicidal event

BACKGROUND

Visits to emergency departments (EDs) for suicidal ideation or a suicide attempt have increased in the past decades. Yet comprehensive models of suicide are scarce, potentially enhancing misunderstandings from health professionals. This study aimed to investigate the applicability of the interpersonal-psychological theory of suicide (IPTS) in a population visiting EDs for suicide-related issues.

METHODS

Three major hypotheses formulated by the IPTS were tested in a sample of 167 individuals visiting EDs for suicidal ideation or a suicide attempt.

RESULTS

As predicted by the IPTS, greater levels of perceived burdensomeness (PB) were associated with presence of current suicidal ideation. However, contrary to the theory assumptions, thwarted belongingness (TB) was not predictive of current suicidal ideation (Hypothesis 1). Similarly, the interaction between PB, TB and hopelessness did not account for the transition from passive to active suicidal ideation (Hypothesis 2). The interaction between active suicidal ideation and fearlessness of death did not either predict the transition from active suicidal ideation to suicidal intent (Hypothesis 3).

LIMITATIONS

The cross-sectional design limited the interpretation of causal hypotheses. Patients visiting EDs during nights and weekends were underrepresented. A general measure of hopelessness was considered, not a measure of hopelessness specifically related to PB and TB.

CONCLUSIONS

Although the three hypotheses were only partially verified, health professionals might consider the IPTS as useful for the management of patient with suicide-related issues. Clinical intervention based on perceived burdensomeness could notably be proposed shortly after ED admission.

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.

Life experiences and the acquired capability for suicide in incarcerated men

Suicide is a leading cause of death in U.S. prisons. Prisoners may be at risk for suicide due to their greater likelihood of experiencing events that promote the acquired capability for suicide. The current study examined the associations of 10 domains of life experiences with the acquired capability for suicide in 399 male prisoners. All life experience domains were associated with acquired capability with certain domains evidencing relatively stronger relations. Results support that aggression, thrill seeking, suicidal thoughts and behaviors, and accidental injury may be particularly important to the development of the acquired capability for suicide in prisoners.

Dimensionality, psychometric properties and population-based norms of the German version of the Revised Acquired Capability for Suicide Scale (ACSS-FAD)

The aim of the present study was the validation of the Acquired Capability for Suicide Scale-Fearlessness about Death (ACSS-FAD) in a large population sample to further establish its reliability and validity, and to provide norm values. We assessed the ACSS-FAD, measures of depression, history of suicidal behavior, and anxiety in a representative sample of the German population (N=2513) and analyzed its dimensionality, invariance across sex and construct validity by means of confirmatory factor analysis, correlational analysis and analysis of variance. The one-factorial structure achieved satisfactory model fit after introducing several correlating error terms. Across sex, partial scalar invariance could be established. Depression and anxiety showed negative associations with the ACSS-FAD while no relation with past suicidal behavior was found. Because mean scores in the ACSS-FAD were affected by sex and age group, sex and age-specific norm values were calculated. Our findings support the one-factorial structure of the ACSS-FAD when the measurement model is slightly modified, pointing out the need of revising the wording of some items. The validity of the measure should be further examined in clinical samples.