'Flash-forwards' and suicidal ideation: A prospective investigation of mental imagery, entrapment and defeat in a cohort from the Hong Kong Mental Morbidity Survey

Picturing self-harm: Investigating flash-forward mental imagery as a proximal and modifiable driver of non-suicidal self-injury

OBJECTIVES

Non-suicidal self-injury (NSSI) is theorized to be reinforced by its emotional consequences. Mental images of NSSI are commonly reported as occurring prior to NSSI. Based on the known functional properties of anticipatory mental imagery as an emotional and motivational amplifier, this study investigated whether NSSI mental imagery constitutes a proximal and dynamic mechanism underpinning NSSI risk.

METHOD

An intensive ecological momentary assessment (EMA) study was conducted to track the occurrence and characteristics of NSSI mental imagery alongside NSSI urge and behavior in naturalistic settings. A sample of N = 43 individuals aged 17 to 24 with a history of repetitive NSSI completed EMA surveys seven times a day for 14 days.

RESULTS

Mental preoccupation in the form of NSSI mental imagery-based flash-forwards to the actions, bodily sensations, and emotional benefits of NSSI was found to occur when NSSI urge was high but not when urge was low. Critically, objective cross-panel analyses showed that higher frequencies of NSSI imagery occurrence predicted greater future NSSI urge and increased likelihood of acting on urge, over and above current urge.

CONCLUSIONS

Mental imagery of NSSI is not simply an epiphenomenal by-product of NSSI urge and may constitute a dynamic and proximal novel intervention target.

The Meaning of Mental Imagery in Acute Suicidal Episodes: A Qualitative Exploration of Lived Experiences

Clinical assessment of suicidal ideation focuses on cognitions in the form of verbal thoughts. However, cognitions also take the shape of mental imagery. The aim of this qualitative study was to explore the meaning of mental imagery in acute suicidal episodes (ASEs). Eight persons with severe previous ASEs participated in repeated in-depth interviews and in the semi-structured Suicidal Cognitions Interview. Textual data from both sources underwent content analysis. All participants experienced suicide-related imagery during ASEs. Analysis resulted in two themes. (1) Suicide-approaching imagery: intrusive looming images that contributed to loss of control, flashforwards that clarified the suicidal solution, or desirable but unattainable images. (2) Suicide preventive imagery: death-alienating, life-affirming, or potentially helpful images. The meaning of mental imagery in ASEs is suggested to be understood in relation to the context of the individual ASE. A narrative approach is encouraged, as is an increased clinical focus on mental imagery in general.

Content and Process of Adolescent Suicide Ideation: Implications for Risk Assessment

This study examined differences in the content and process of suicide ideation between adolescents presenting with recent suicide ideation or a suicide attempt in clinical settings. Across two combined study samples, adolescents (N = 229; 79% female; 73% Hispanic/Latine), ages 12-19, presenting with a recent suicide attempt, recent suicide ideation with a past suicide attempt history, or recent suicide ideation with no past suicide attempt history were interviewed in detail about the process and content of their suicide ideation. The group with suicide ideation and a past suicide attempt more often reported that their recent ideation lasted greater than 4 h compared to those with suicide ideation but no past suicide attempt history. The suicide attempt group more often considered ingestion as their first method of attempt, compared to the other two suicide ideation groups, and less often considered "other" methods (e.g., jumping from a height or onto train/traffic, hanging). Wish to die was lower in the ideation-only group, compared to both other groups. Separate analyses from Study 2 suggested that the majority of adolescents' suicide ideation contained imagery; however, a higher proportion of adolescents with suicide ideation and a past suicide attempt reported imagery in their ideation than those with ideation but no past attempt. Understanding what adolescents think about when they consider suicide and how they think about it may be informative about risk of a suicide attempt.

Narrative-based autobiographical memory interventions for PTSD: a meta-analysis of randomized controlled trials

Introduction

The aim of this systematic review and meta-analysis is to evaluate the efficacy of narrative-based interventions (NBIs) for individuals with post-traumatic stress disorder (PTSD). Investigating the efficacy of NBIs should yield insight on autobiographical memory (AM) phenomena implicated in PTSD onset and recovery, leading to improved intervention protocols. Furthermore, by analyzing how NBIs influence maladaptive AM distortions, we hope to shed light on the theorized narrative architecture of AM more generally.

Methods

A systematic literature search was conducted according to PRISMA and Cochrane guidelines in MEDLINE, EMBASE, PsychINFO, and PubMed. Additional studies were then also identified from the reference lists of other relevant literature and considered for inclusion. Studies were then evaluated for adherence to the inclusion/exclusion criteria and assessed for risk of bias. Various meta-analyses were performed on included studies to understand how NBIs may or may not influence the overall effect size of treatment.

Results

The results of the meta-analysis of 35 studies, involving 2,596 participants, suggest that NBIs are a viable and effective treatment option for PTSD, yielding a statistically significant within-group effect size and decrease in PTSD symptomatology at both post-treatment [g = 1.73, 95% CI (1.23-2.22)] and 3-9 month follow-up assessments [g = 2.33, 95% CI (1.41-3.26)]. Furthermore, the difference in effect sizes between NBIs compared to active and waitlist controls was statistically significant, suggesting that NBIs are superior. Sub-analyses showed that NET provided a stronger effect size than FORNET, which may be due to the nature of the traumatic event itself and not the treatment protocol. While evidence of small study and publication bias was present, a weight-function model and trim-and-fill method suggested it was not influencing the overall results.

Discussion

This meta-analysis presents strong evidence supporting the use of NBIs in the treatment of PTSD. Clear similarities can be identified between NBIs included in this analysis that make them distinct from non-NBI interventions, which are reviewed in the discussion. Controlled comparisons between NBIs and non-NBIs would help to further understand AM mechanisms of action implicated in recovery and how various interventions facilitate them. Future research should also aim to elucidate the full range of AM impairment in individuals with PTSD to gain insight on how other memory capabilities, such as the ability to mentally simulate the future, are implicated in the pathogenesis of PTSD.

The Suicidal Intrusions Attributes Scale (SINAS): a new tool measuring suicidal intrusions

Introduction

Suicidal intrusions are uncontrollable, intrusive mental images (e. g., visualizing a future suicidal act). They may also be called suicidal "flash-forwards." Despite the importance of integrating the assessment of suicidal intrusions into a clinical routine assessment, quick self-report screening instruments are lacking. This study describes the development of a new instrument-Suicidal Intrusions Attributes Scale (SINAS)-to assess the severity and characteristics of suicidal intrusions and examines its psychometric properties.

Method

The sample included currently suicidal outpatients with elevated levels of depression recruited across mental health institutions in the Netherlands (N = 168). Instruments administered were 10-item SINAS, the Suicidal Ideation Attributes Scale (SIDAS), the Prospective Imagery Task (PIT), four-item Suicidal Cognitions Interview (SCI), and the Beck Depression Inventory (BDI-II).

Results

An exploratory factor analysis identified a one-factor structure. The resulting SINAS demonstrated good internal consistency (Cronbach's α = 0.91) and convergent validity, as expected.

Discussion

Overall, this study demonstrated acceptable levels of reliability and validity of the measure in a depressed clinical population with suicidal ideation. The SINAS may be a useful screening tool for suicidal intrusions in both research and clinical settings.

Mental imagery of suicide and non-suicidal self-injury: A meta-analysis and systematic review

BACKGROUND

The vast majority of research on, and clinical assessment of, cognitions related to suicide and non-suicidal self-injury (NSSI) has focused on verbal thoughts. And yet, mental imagery is more realistic and emotionally arousing than verbal thoughts.

METHODS

We conducted a systematic review and meta-analysis documenting the prevalence of suicidal and NSSI mental imagery and describing the content and characteristics of suicidal and NSSI mental imagery, links between suicidal and NSSI mental imagery and suicidal and NSSI behavior, and how to intervene on suicidal and NSSI mental imagery. Studies published through December 17, 2022 were identified through a systematic search of MEDLINE and PsycINFO.

RESULTS

Twenty-three articles were included. Prevalence rates of suicidal (73.56%) and NSSI (84.33%) mental imagery were high among clinical samples. Self-harm mental imagery commonly depicts engagement in self-harm behavior and is experienced as vivid, realistic, and preoccupying. When experimentally induced, self-harm mental imagery reduces physiological and affective arousal. Preliminary evidence suggests that suicidal mental imagery is associated with suicidal behavior.

CONCLUSIONS

Suicidal and NSSI mental imagery are highly prevalent and may be associated with heightened risk for self-harm behavior. Assessments and interventions for self-harm should consider incorporating and addressing suicidal and NSSI mental imagery to mitigate risk.

Nurses' Experiences of Suicide Prevention in Primary Health Care (PHC) - A Qualitative Interview Study

AIM

The purpose was to describe nurses' experiences of suicide prevention work in primary health care (PHC).

BACKGROUND

Suicide is the tenth most common cause of death among adults. PHC has an important role in suicide prevention work, as patients often had contact with PHC before their suicide rather than with specialist psychiatric care. Nurses often have the first contact with the patient and are responsible for triage and assessment, making them important in suicide prevention work. Previous studies shed light on suicide prevention in a primary care context, but the nurses' voices are missing.

METHODS

Fifteen qualitative interviews were conducted with nurses in primary health care. Data was analyzed according to conventional content analysis techniques.

FINDINGS

Nurses may avoid asking questions about suicidality for fear of what to do with the answer. To support the nurses' ability in suicide prevention work, both educational and practical experience are fundamental. There was a lack of clarity about who is carrying responsibility for the patient, and it turned out to be difficult to help the patient move further to the next care institution. There was a need for guidelines as well as routines for collaboration with other care actors in suicide prevention work.

CONCLUSION

The PHC organization does not support nurses in suicide prevention, therefore they need the right conditions for their work. Suicide prevention needs to be given greater focus and space within education as well as training in the ongoing clinical work, which can be performed with less extensive efforts.

Suicidal Mental Imagery: Investigating a Novel Marker of Suicide Risk

Rates of suicidal ideation and behavior are high and increasing in emerging adulthood. Research focused on suicidal ideation as a predictor of suicidal behavior has nearly exclusively conceptualized suicidal ideation as verbal thoughts about suicide. Emerging research suggests, however, that mentally imagining suicide may be even more impairing than verbal thoughts about suicide. Thirty-nine emerging adults with a lifetime history of suicidal cognitions completed self-report assessments of characteristics of their suicidal cognitions, histories of suicide plans and behavior, and the degree to which their suicidal cognitions took the form of mental imagery or verbal thought. Suicidal mental imagery predicted more intense and longer duration of suicidal cognitions, a higher likelihood of having made a suicide plan, and a higher likelihood of having made a suicide attempt over and above suicidal verbal thoughts. Thus, suicidal mental imagery could provide a novel target for suicide assessment and intervention for emerging adults.

Defeat, entrapment, and suicidal ideation: Twelve-month trajectories

BACKGROUND

Defeat and entrapment have been highlighted in the development of suicidal ideation within the Integrated Motivational-Volitional model of suicidal behavior. Research suggests that entrapment has to be differentiated into internal and external entrapment. The aim of this study was to investigate the associations between defeat, internal, external entrapment, and suicidal ideation within and prospectively over measurements.

METHODS

A sample of 308 psychiatric inpatients (53% female) aged 18 to 81 years (M = 36.92, SD = 14.30) was assessed for the four constructs after admission to a psychiatric ward and six, nine, and twelve months later. Multilevel analyses were conducted to examine associations.

RESULTS

Defeat was associated with (a change in) internal and external entrapment. Defeat predicted a change in internal entrapment over time. Defeat and internal, but not external, entrapment were associated with (a change in) suicidal ideation. Internal entrapment was able to predict suicidal ideation. Internal entrapment and defeat predicted a change in suicidal ideation over time.

CONCLUSION

Results highlight the importance to distinguish between internal and external entrapment, and their specific association with suicidal ideation. Perceptions of internal entrapment are of central relevance when experiencing suicidal ideation and should be considered in clinical practice.

Mental imagery in adolescent PTSD patients after child abuse: a comparison with matched healthy controls

BACKGROUND

Intrusive mental imagery (MI) plays a crucial role in the maintenance of posttraumatic stress disorder (PTSD) in adults. Evidence on the characteristics of MI in adolescents suffering from PTSD is sparse. The aim of this study was to thoroughly assess MI in an adolescent sample suffering from PTSD after the experience of childhood sexual abuse and/or childhood physical abuse (CA).

METHODS

Thirty-two adolescents with a primary diagnosis of PTSD after CA and 32 adolescents without any mental disorder and without a history of CA, matched for age and gender, completed questionnaires assessing the characteristics of negative and positive MI, as well as images of injury and death that lead to positive emotions (ID-images).

RESULTS

The PTSD group reported significantly more frequent, more vivid, more distressing and more strongly autobiographically linked negative MI compared to the control group. Although positive MI was highly present in both groups (PTSD: 65.6%; controls: 71.9%), no significant differences emerged between the two groups regarding the distinct characteristics of positive MI. The frequency of the ID-images did not significantly differ between the two groups (PTSD: 21.9%; controls: 9.4%), although the ID-images were more vivid in the PTSD group.

DISCUSSION

Negative MI appears to be crucial in adolescent PTSD, whilst positive MI are unexpectedly common in both the PTSD and the control group. The role of positive MI as well as that of ID-images remain unclear. Specific interventions for changing negative MI that are tailored to the developmental challenges in adolescents with PTSD should be developed.

TRIAL REGISTRATION

Some of the PTSD patients in this study were also part of a randomized controlled trial on Developmentally adapted Cognitive Processing Therapy (D-CPT). This trial was registered at the German Clinical Trial Registry (GCTR), DRKS00004787 , 18 March 2013.

Followers' unclear demands during the COVID-19 pandemic can undermine leaders' well-being: A moderated mediation model from an entrapment perspective

Although effective leaders are important for reducing employee stress during the COVID-19, limited studies have examined how follower behaviors can influence leader stress and well-being during the COVID-19. This study draws on defeat-entrapment theory to examine how followers' unclear demands during the COVID-19 consequently impact leaders' psychological states and well-being. We conducted a three-wave time-lagged investigation with a sample of 281 leaders in the United Kingdom and found that followers' unclear demands could generate feelings of entrapment in leaders, leading to decreased levels of well-being outcomes in leaders. Importantly, we found that leaders who have higher levels of leadership responsibility during the COVID-19 are likely to feel trapped by followers' unclear demands. They are also likely to face higher levels of feelings of entrapment and impaired well-being compared with leaders who have lower levels of leadership responsibility. We discuss the implications for theories and practices, as well as directions for future research.

Disturbed sleep as a clinical marker of wish to die: A smartphone monitoring study over three months of observation

BACKGROUND

Smartphone monitoring could contribute to the elucidation of the correlates of suicidal thoughts and behaviors (STB). In this study, we employ smartphone monitoring and machine learning techniques to explore the association of wish to die (passive suicidal ideation) with disturbed sleep, altered appetite and negative feelings.

METHODS

This is a prospective cohort study carried out among adult psychiatric outpatients with a history of STB. A daily questionnaire was administered through the MEmind smartphone application. Participants were followed-up for a median of 89.8 days, resulting in 9,878 person-days. Data analysis employed a machine learning technique called Indian Buffet Process.

RESULTS

165 patients were recruited, 139 had the MEmind mobile application installed on their smartphone, and 110 answered questions regularly enough to be included in the final analysis. We found that the combination of wish to die and sleep problems was one of the most relevant latent features found across the sample, showing that these variables tend to be present during the same time frame (96 hours).

CONCLUSIONS

Disturbed sleep emerges as a potential clinical marker for passive suicidal ideation. Our findings stress the importance of evaluating sleep as part of the screening for suicidal behavior. Compared to previous smartphone monitoring studies on suicidal behavior, this study includes a long follow-up period and a large sample.

Impact of Web-Based Sharing and Viewing of Self-Harm-Related Videos and Photographs on Young People: Systematic Review

BACKGROUND

Given recent moves to remove or blur self-harm imagery or content on the web, it is important to understand the impact of posting, viewing, and reposting self-harm images on young people.

OBJECTIVE

The aim of this study is to systematically review research related to the emotional and behavioral impact on children and young people who view or share web-based self-harm-related videos or images.

METHODS

We searched databases (including Embase, PsychINFO, and MEDLINE) from January 1991 to February 2019. Search terms were categorized into internet use, images nonspecific and specific to the internet, and self-harm and suicide. Stepwise screening against specified criteria and data extraction were completed by two independent reviewers. Eligible articles were quality assessed, and a narrative synthesis was conducted.

RESULTS

A total of 19 independent studies (20 articles) were included. Of these, 4 studies focused on images, 10 (11 articles) on videos, and 5 on both. There were 4 quantitative, 9 qualitative, and 7 mixed methods articles. In total, 11 articles were rated as high quality. There has been an increase in graphic self-harm imagery over time. Potentially harmful content congregated on platforms with little moderation, anonymity, and easy search functions for images. A range of reactions and intentions were reported in relation to posting or viewing images of self-harm: from empathy, a sense of solidarity, and the use of images to give or receive help to potentially harmful ones suggesting new methods, normalization, and exacerbation of self-harm. Viewing images as an alternative to self-harm or a creative outlet were regarded in 2 studies as positive impacts. Reactions of anger, hostility, and ambivalence have been reported. There was some evidence of the role of imitation and reinforcement, driven partly by the number of comments and wound severity, but this was not supported by time series analyses.

CONCLUSIONS

Although the results of this review support concern related to safety and exacerbation of self-harm through viewing images of self-harm, there may be potential for positive impacts in some of those exposed. Future research should evaluate the effectiveness and potential harms of current posting restrictions, incorporate user perspectives, and develop recovery-oriented content. Clinicians assessing distressed young people should ask about internet use, including access to self-harm images, as part of their assessment.

Suicidal Mental Imagery in Psychiatrically Hospitalized Adolescents

Suicide is the second leading cause of death in adolescents and suicide rates in this population have increased in recent years. A critical step in preventing suicide is improving the accuracy of suicide risk assessment. Measurement of suicidal cognitions typically emphasizes assessment of verbal thoughts about suicide. Recent research suggests, however, that suicidal mental imagery, or mentally imagining suicide-related content, may be even more strongly associated with suicidal behavior. No research has evaluated suicidal mental imagery in adolescents, however. The present study evaluated suicidal mental imagery and suicidal verbal thoughts in a sample of adolescents (N = 159) admitted to an adolescent psychiatric inpatient unit. Of those adolescents who reported suicidal cognitions, 63.73% reported suicidal mental imagery. Adolescents who reported suicidal mental imagery had 2.40 greater odds of having made a suicide attempt, after accounting for history of suicidal verbal thoughts and relevant covariates. Findings suggest that suicidal mental imagery should be directly assessed when evaluating suicide risk, and that treatments may be optimized by targeting both suicidal verbal thoughts and suicidal mental imagery.

The reconstructive nature of involuntary autobiographical memories

Influential clinical theories propose that parts of traumatic or stressful events are stored in an unprocessed, purely perceptual form, which is inaccessible for voluntary retrieval but may spontaneously return to consciousness involuntarily in response to matching cues. This leads to perceptually vivid, and largely veridical involuntary memories of the traumatic scene, remembered with the original emotions and from the same vantage point as during the event. Several lines of evidence contradict this position. First, involuntary memories are not more veridical than memories retrieved deliberately. Second, involuntary memories for trauma-related events are not more frequently remembered with the original first-person perspective, and individuals with PTSD do not report more first-person involuntary memories than individuals without PTSD. Third, involuntary memories of stressful moments that are subjectively experienced as repetitive do not come to mind in a fixed and unchangeable form. Fourth, involuntary memories do not have privileged access to the most emotional moments (so-called hotspots) of a stressful event and the content and choice of hotspots change over time. Fourth, although involuntary memories are associated with enhanced emotional impact, this does not imply reactivation of the original emotion. We conclude that involuntary memories, although effortless, are products of (re)constructive processes.

Romance Scams: Romantic Imagery and Transcranial Direct Current Stimulation

Love has an enormous effect on mental health. One does not need an actual romantic relationship to be in love. Indeed, romantic love can be built upon without frequent or real-life encounters, such as with a stranger from a matching website. With the advancement of the Internet and the influence of coronavirus disease, it is believed that these distant romantic relationships and related romance scams are burgeoning. Often, the victims of scams keep emotionally attached to the scammer even after the lie is revealed, which is hypothesized to be attributed to the aberrantly exaggerated romantic imagery of the victims. It is observed that many victims suffer from symptoms similar to a post-traumatic stress disorder, and some even consider suicide. However, there is scant literature on this topic. In this article, it is further postulated that the aberrant romantic imagery might be associated with impulsive acts such as suicide once the ideal but fake romantic relationship is dissolved. Thereafter, it is further speculated that manipulation of the visual network, possibly by transcranial direct current stimulation (tDCS), might be a promising treatment.

Thinking about suicidal thinking

Suicide has emerged as a major cause of death from non-communicable disease worldwide, leading to a burgeoning interest in its prevention. Naturally, in this context one of the focuses of research and clinical interest is the presence of suicidal thinking-a potentially identifiable and reversible precursor of suicide-with much interest lately being in the relation between suicidal thinking and suicidal behaviour. In this Personal View we argue that, notwithstanding important and nuanced research into the nature of these phenomena, the field currently suffers from approaches to the terminology and reporting of suicidal thinking that pay insufficient regard to key features of its definition, and that these have clinical and research implications.

Study protocol for a mixed methods prospective cohort study to explore experiences of care following a suicidal crisis in the Australian healthcare system

INTRODUCTION

For individuals presenting to the emergency department (ED) for a suicide attempt, the period after discharge from hospital is marked by heightened vulnerability for further suicide attempts. Effective care following a suicidal crisis has the potential to significantly decrease this risk. The current study aims to examine the impact of the LifeSpan multilevel suicide prevention model on experiences of care following a suicidal crisis. Perspectives from healthcare consumers (individuals who have presented to the ED following a suicidal crisis), carers, and health professionals will be explored. The LifeSpan model is currently being evaluated as a high-fidelity trial in four geographically defined regions in New South Wales, Australia.

METHODS AND ANALYSIS

This study will use a mixed methods prospective cohort design. Quantitative data collection includes a structured survey, administered to healthcare consumers from LifeSpan sites and control sites. Two cohorts of healthcare consumers will be recruited 12 months apart with baseline assessment occurring within 18 months of the ED presentation, and follow-up 12 months after the initial assessment. Survey participants will be recruited online and through participating EDs, mental health organisations and aftercare services. Qualitative interview data from healthcare consumers, carers who have accompanied a loved one to the ED following a suicidal crisis and health professionals who provide care to people at risk of suicide will be collected concurrently with the recruitment of the first cohort of survey participants. Purposive and convenience sampling techniques will be used for recruitment of interview participants. The primary outcome for this study will be healthcare consumers' experiences of service provided at the ED. Analysis will be undertaken of the change over time within LifeSpan sites, as well as between LifeSpan sites and control sites, using mixed effects repeated measures models as principal means of data analysis.

ETHICS AND DISSEMINATION

This research has been approved by the Hunter New England Human Research Ethics Committee (HREC/17/HNE/144). Results will be disseminated via conferences and peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ACTRN12617000457347.

Suicidal Imagery in Borderline Personality Disorder and Major Depressive Disorder

A better understanding of suicidal behavior is important to detect suicidality in at-risk populations such as patients with borderline personality disorder (BPD), posttraumatic stress disorder (PTSD), and major depressive disorder (MDD). Suicidal tendencies are clinically assessed by verbal thoughts rather than by specifically asking about mental images. This study examines whether imagery and verbal thoughts about suicide occur and differ between patients with BPD with and without comorbid PTSD compared to patients with MDD (clinical controls). All patient groups experienced suicide-related images. Patients with BPD with comorbid PTSD reported significantly more vivid images than patients with MDD. Severity of suicidal ideation, number of previous suicide attempts, and childhood traumata were significantly associated with suicidal imagery across all patient groups. The authors demonstrate for the first time that suicide-related mental imagery occurs in BPD and is associated with suicidal ideation. This finding highlights the importance of assessing mental imagery related to suicide in clinical practice.

Imaginator: A Proof-of-Concept Feasibility Trial of a Brief Imagery-Based Psychological Intervention for Young People Who Self-Harm

OBJECTIVES

The Imaginator study tested the feasibility of a short mental imagery-based psychological intervention for young people who self-harm and used a stepped-wedge design to investigate effects on self-harm frequency reduction at 3 and 6 months.

METHOD

A total of 38 participants aged 16-25 were recruited via community self-referral and mental health services. Participants were randomized to immediate delivery of Functional Imagery Training (FIT) or usual care followed by delayed delivery after 3 months. FIT comprised two face-to-face sessions, five phone sessions, and use of a smartphone app. Outcomes' assessment was blind to allocation.

RESULTS

Three quarters of those who began treatment completed face-to-face sessions, and 57% completed five or more sessions in total. Self-harm frequency data were obtained on 76% of the sample at 3 months (primary outcome) and 63% at 6 months. FIT produced moderate reductions in self-harm frequency at 3 months after immediate (d = 0.65) and delayed delivery (d = 0.75). The Immediate FIT group maintained improvements from 3 to 6 months (d = 0.05). Participants receiving usual care also reduced self-harm (d = 0.47).

CONCLUSIONS

A brief mental imagery-based psychological intervention targeting self-harm in young people is feasible and may comprise a novel transdiagnostic treatment for self-harm.

Understanding suicidal ideation and behaviour in individuals with chronic pain: a review of the role of novel transdiagnostic psychological factors

Individuals with chronic pain are at an elevated risk of suicide, yet psychosocial factors that might be involved in increasing or decreasing vulnerability for suicidal ideation and behaviour have received little attention. Extant literature on the topic of suicide in individuals with chronic pain incorporates only a few of the wide array of known vulnerability and protective factors. This Review focuses on transdiagnostic psychological processes, (ie, those of relevance for both chronic pain and suicide). We reviewed a selection of published literature on chronic pain and suicide, concentrating on previously unexplored and underexplored lines of research, including future orientation, mental imagery, and psychological flexibility. A greater degree of crosspollination between the fields of chronic pain and suicide research is required to progress our understanding of why some people with chronic pain become suicidal and others do not.

Mental images, entrapment and affect in young adults meeting criteria of nonsuicidal self-injury disorder (NSSID) - a daily diary study

BACKGROUND

Incidents of nonsuicidal self-injury (NSSI) are often accompanied by mental images which could be perceived as distressing and/or soothing; yet existing data is derived from participants with a history of NSSI using retrospective methods. This study investigated mental images related to NSSI ("NSSI-images"), and their relationship to the proposed Nonsuicidal Self-Injury Disorder (NSSID).

METHODS

An e-mail was sent to all female students of the local University providing the link to an online screening and 201 students with a history of repetitive NSSI responded. Nineteen eligible participants meeting criteria of NSSID (mean age = 25; 32% with migrant background) further completed a baseline interview and a ten-day-diary protocol.

RESULTS

Among the sample of N = 201, 83.6% reported NSSI-images. In the subsample of n = 19 diagnosed with NSSID, the frequencies of NSSI and NSSI-images were correlated; about 80% of the most significant NSSI-images were either of NSSI or of an instrument associated with NSSI (i.e., a razorblade). In the diary, 53% of the sample self-injured. NSSI-images were reported on 94% of NSSI-days, and on days with NSSI and NSSI-images, the images almost always occurred first; the images were overall perceived as twice more distressing than comforting. Images on NSSI-days were characterized by more comfort, intrusiveness and compellingness yet less vividness, and increased subsequent positive and negative affect compared to non-NSSI days. NSSI-days were further marked by increased entrapment beliefs and increased negative yet decreased positive affect at night. These results were non-significant.

LIMITATIONS

Due to non-significant results among a small sample size and a low rate of NSSI among the NSSID-group, results remain preliminary.

CONCLUSIONS

The study provides information on feasibility and methodological challenges such as intervention effects of the diary. NSSI-images may be common among individuals who engage in NSSI; they may capture ambivalent (positive and negative) appraisals of NSSI and thus play a role in NSSI and possibly a disorder such as NSSID. The preoccupation with NSSI (Criterion C of NSSID in DSM-5) may as well be imagery-based.

REGISTRATION

The study was retrospectively registered with the DRKS under the number DRKS00011854.

Cognitive Behavioural Therapy for Nightmares for Patients with Persecutory Delusions (Nites): An Assessor-Blind, Pilot Randomized Controlled Trial

OBJECTIVE

Nightmares are relatively common in patients experiencing psychosis but rarely assessed or treated. Nightmares may maintain persecutory delusions by portraying fears in sensory-rich detail. We tested the potential benefits of imagery-focused cognitive behavioural therapy (CBT) for nightmares on nightmare severity and persecutory delusions.

METHOD

This assessor-blind parallel-group pilot trial randomized 24 participants with nightmares and persecutory delusions to receive CBT for nightmares delivered over 4 weeks in addition to treatment as usual (TAU) or TAU alone. Assessments were at 0, 4 (end of treatment), and 8 weeks (follow-up). Feasibility outcomes assessed therapy uptake, techniques used, satisfaction, and attrition. The primary efficacy outcome assessed nightmare severity at week 4. Analyses were intention to treat, estimating treatment effect with 95% confidence intervals (CIs).

RESULTS

All participants offered CBT completed therapy (mean [SD], 4.8 [0.6] sessions) with high satisfaction, and 20 (83%) participants completed all assessments. Compared with TAU, CBT led to large improvements in nightmares (adjusted mean difference = -7.0; 95% CI, -12.6 to -1.3; d = -1.1) and insomnia (6.3; 95% CI, 2.6 to 10.0; d = 1.4) at week 4. Gains were maintained at follow-up. Suicidal ideation was not exacerbated by CBT but remained stable to follow-up, compared with TAU, which reduced at follow-up (6.8; 95% CI, 0.3 to 3.3; d = 0.7). CBT led to reductions in paranoia (-20.8; 95% CI, -43.2 to 1.7; d = -0.6), although CIs were wide. Three serious adverse events were deemed unrelated to participation (CBT = 2, TAU = 1).

CONCLUSIONS

CBT for nightmares is feasible and may be efficacious for treating nightmares and comorbid insomnia for patients with persecutory delusions. It shows promise on paranoia but potentially not on suicidal ideation.

Cognitive Behavioural Therapy Suicide Prevention (CBT-SP) imagery intervention: a case report

Very little clinical work or research to date has focused on the prioritization of suicidal imagery intervention in the stabilization of risk. Current Cognitive Behavioural Therapy Suicide Prevention (CBT-SP) does not specifically address suicidal imagery as a priority intervention. This paper prioritizes imagery modification as the central task of therapy with the suicidal client. This is a single subject case review describing specific imagery interventions used to destabilize the comforting component of suicidal images, de-glamourize the suicidal image as a problem-solving method and the reconstruction of new images to offset the emotional grasp of both ‘flash-forward’ violent suicidal images and suicidal ‘daydreaming’ rumination. It is hypothesized that when suicidal images become less emotionally charged, the desire to act upon suicide decreases. Focusing on imagery intervention as a priority aims to stabilize risk in a more clinically specific and targeted way. Rob is a 19-year-old depressed young man with chronic suicidal ideation/images with repeated suicide attempts. All GP referrals are of a crisis nature since the age of 16. He was referred to a CBT clinician with specific training and experience in CBT-SP who proposed the following brief imagery intervention. Socialization to treatment rationale was pivotal at the outset to help facilitate strong therapeutic alliance, ‘buy-in’ to the intended de-glamourization of suicide planning/daydreaming/rumination and the effects of intrusive ‘flash-forward’ images on emotional well-being. Therapy was facilitated weekly, supported by telephone contact, on an out-patient basis in the HSE (Health Service Executive) Irish Adult Mental Health service. The care plan and interventions were supported by access to the 24-hour acute Adult Mental Health services, as required. There was no requirement for direct client engagement with the acute services. Rob engaged with five treatments of CBT-SP imagery intervention and full stabilization of risk to self by suicide was achieved. At the time of writing, Rob is alive, has no engagement with the services and no further GP referral requests for intervention. Despite Rob leaving therapy before full completion, brief targeted suicidal imagery intervention was observed to stabilize the risk of suicidal behaviour. This young man has completed his schooling, engaged in ‘life’ planning rather than ‘death’ planning and has not required further intervention from this service. Further research is required to engage frontline clinicians on the merits of suicidal imagery assessment in routine clinical practice.

Key learning aims

(1)

Exploring the psychology of suicidal ideation: A theory driven network analysis

Two leading theories within the field of suicide prevention are the interpersonal psychological theory of suicidal behaviour (IPT) and the integrated motivational-volitional (IMV) model. The IPT posits that suicidal thoughts emerge from high levels of perceived burdensomeness and thwarted belongingness. The IMV model is a multivariate framework that conceptualizes defeat and entrapment as key drivers of suicide ideation. We applied network analysis to cross-sectional data collected as part of the Scottish Wellbeing Study, in which a nationally representative sample of 3508 young adults (18-34 years) completed a battery of psychological measures. Network analysis can help us to understand how the different theoretical components interact and how they relate to suicide ideation. Within a network that included only the core factors from both models, internal entrapment and perceived burdensomeness were most strongly related to suicide ideation. The core constructs defeat, external entrapment and thwarted belonginess were mainly related to other factors than suicide ideation. Within the network of all available psychological factors, 12 of the 20 factors were uniquely related to suicide ideation, with perceived burdensomeness, internal entrapment, depressive symptoms and history of suicide ideation explaining the most variance. None of the factors was isolated, and we identified four larger clusters: mental wellbeing, interpersonal needs, personality, and suicide-related factors. Overall, the results suggest that relationships between suicide ideation and psychological risk factors are complex, with some factors contributing direct risk, and others having indirect impact.

Treating repetitive suicidal intrusions using eye movements: study protocol for a multicenter randomized clinical trial

BACKGROUND

Suicide is a major public health problem, and it remains unclear which processes link suicidal ideation and plans to the act of suicide. Growing evidence shows that the majority of suicidal patients diagnosed with major depression or bipolar disorder report repetitive suicide-related images and thoughts (suicidal intrusions). Various studies showed that vividness of negative as well as positive intrusive images may be reduced by dual task (e.g. eye movements) interventions taxing the working memory. We propose that a dual task intervention may also reduce frequency and intensity of suicidal imagery and may be crucial in preventing the transition from suicidal ideation and planning to actual suicidal behaviour. This study aims a) to evaluate the effectiveness of an Eye Movement Dual Task (EMDT) add-on intervention targeting suicidal imagery in depressed patients, b) to explore the role of potential moderators and mediators in explaining the effect of EMDT, and c) to evaluate the cost-effectiveness of EMDT.

METHODS

We will conduct a multi-center randomized clinical trial (RCT) evaluating the effects of EMDT in combination with usual care (n = 45) compared to usual care alone (n = 45). Participants will fill in multiple online batteries of self-report questionnaires as well as complete a semi-structured interview (Intrusion Interview), and online computer tasks. The primary outcome is the frequency and intrusiveness of suicidal imagery. Furthermore, the vividness, emotionality, and content of the suicidal intrusions are evaluated; secondary outcomes include: suicidal behaviour and suicidal ideation, severity of depression, psychological symptoms, rumination, and hopelessness. Finally, potential moderators and mediators are assessed.

DISCUSSION

If proven effective, EMDT can be added to regular treatment to reduce the frequency and vividness of suicidal imagery.

TRIAL REGISTRATION

The study has been registered on October 17th, 2018 at the Netherlands Trial Register, part of the Dutch Cochrane Centre ( NTR7563 ).

Mental imagery in psychiatry: conceptual & clinical implications

Mental imagery refers to the experience of perception in the absence of external sensory input. Deficits in the ability to generate mental imagery or to distinguish it from actual sensory perception are linked to neurocognitive conditions such as dementia and schizophrenia, respectively. However, the importance of mental imagery to psychiatry extends beyond neurocognitive impairment. Mental imagery has a stronger link to emotion than verbal-linguistic cognition, serving to maintain and amplify emotional states, with downstream impacts on motivation and behavior. As a result, anomalies in the occurrence of emotion-laden mental imagery has transdiagnostic significance for emotion, motivation, and behavioral dysfunction across mental disorders. This review aims to demonstrate the conceptual and clinical significance of mental imagery in psychiatry through examples of mood and anxiety disorders, self-harm and suicidality, and addiction. We contend that focusing on mental imagery assessment in research and clinical practice can increase our understanding of the cognitive basis of psychopathology in mental disorders, with the potential to drive the development of algorithms to aid treatment decision-making and inform transdiagnostic treatment innovation.

The German Impact of Future Events Scale (IFES-S): Adaption and Validation for Clinical Samples

Prospective intrusive mental images occur frequently among several psychological disorders. Their assessment is an important tool since the imagination of events can drive future behavior, such as suicidal acts. One valid measure evaluating those prospective images is the impact of future events scale (IFES). However, to date, there is no German equivalent to the English IFES. Therefore, the aim of the present study was to adapt and validate the IFES at hand of a clinical sample and a healthy control sample.After translation, item analyzes were conducted, and as a result, four items were excluded from further analysis resulting in the German short version of the IFES, the IFES-S. Construct validity of the German IFES-S was tested through correlational analysis with convergent and divergent measures. Specificity and sensitivity were assessed through ROC analysis. The German IFES-S showed good internal consistency for the overall measurement with a Cronbach's α of .93. Additionally, it displayed good convergent and divergent validity. An optimal cutoff score of 23 was established to discriminate between clinical populations and healthy controls. In summary, the German IFES-S promises to be a valid self-report instrument for the assessment of prospective intrusive imagery within the context of clinical samples.

Spontaneous future cognitions: an integrative review

Spontaneous future cognitions refer to mental representations about the future that enter consciousness with no immediately preceding attempt of bringing them to mind. They are studied under different terms in several areas of psychology, but with little interdisciplinary exchange of findings and theoretical developments. Different conceptions of spontaneous future cognition derive from separate literatures and are rarely considered together, leaving their potential conceptual overlaps as well as their unique features unclarified. In this article, I review research on spontaneous future cognitions in relation to mind wandering, involuntary episodic future thoughts, and intrusive future imagery in cravings and clinical disorders. I conclude that more research is needed to clarify the potential functions served by spontaneous future cognitions in everyday life, under which conditions they may become dysfunctional, how they are triggered by situational cues, and how their content may be constrained by motivational factors and beliefs. The burgeoning field of spontaneous future cognitions forms a promising novel approach to the cognitive and motivational regulation of behavior in everyday life.

From ideation to action: Differentiating between those who think about suicide and those who attempt suicide in a national study of young adults

BACKGROUND

Although many suicide risk factors have been identified, there is still relatively little known about the factors that differentiate those who think about suicide from those who make a suicide attempt.

AIMS

Using the integrated motivational-volitional model (IMV) of suicidal behaviour as a framework, this study hypothesised that (i) motivational and volitional phase factors would differentiate non-suicidal controls from those who had a history of suicidal ideation or suicide attempts, and (ii) within a multivariable model only volitional phase factors would differentiate between those who had a history of suicidal ideation and those who had attempted suicide.

METHOD

The Scottish Wellbeing Study (n = 3508) is a nationally representative study of young people (18-34 years) recruited throughout Scotland. Using multinomial regression analysis, three groups (non-suicidal control (n = 2534), lifetime suicide ideation (n = 498) and lifetime suicide attempt (n = 403) groups) were compared on motivational and volitional phase variables.

RESULTS

Consistent with the IMV model, motivational and volitional phase variables differentiated the control group from both the ideation and attempt groups. Only volitional phase variables differentiated between the suicide attempt group and the suicidal ideation group in the multivariable model; with those reporting a suicide attempt being higher on acquired capability, mental imagery about death, impulsivity, and being more likely to know a friend who had made a suicide attempt. Having a family member or friend die by suicide or a family member attempt suicide did not differentiate between the groups.

LIMITATIONS

The findings were based on cross-sectional data derived from self-report measures.

CONCLUSIONS

These findings provide further support for the IMV model, and highlight potential targets for clinical intervention.

Thoughts, images, and appraisals associated with acting and not acting on the urge to self-injure

OBJECTIVES

The aim of this study was to examine the frequency, content, and appraisals of thoughts and images occurring during urges to engage in non-suicidal self-injury (NSSI).

METHOD

Undergraduates (N = 154) with a history of NSSI completed an online survey of their thoughts, images, and appraisals when they acted on urges to engage in NSSI as well as when they resisted urges to self-injure.

RESULTS

Most (>90%) participants reported experiencing both thoughts and images during urges to engage in NSSI. During urges that resulted in self-injury, self-critical and hopeless thoughts were most distressing, and thoughts about relief from emotional distress were most comforting. Images of the anticipated injury were most common. During urges that did not result in self-injury themes of the futility of NSSI, positive self-talk, and the impact on others were most common. Images were most frequently of the negative impact on self and others, and the anticipated injury. Appraisals encouraging NSSI occurred when individuals did and did not act on their urges, but concurrent strong discouraging appraisals appeared to be protective on occasions when urges did not result in self-injury.

LIMITATIONS

Retrospective self-report was used to assess cognitive content. Generalisability of findings to non-student samples needs to be assessed.

CONCLUSIONS

Findings from this study may inform comprehensive assessment of thoughts and images associated with urges to engage in NSSI. NSSI interventions may need to promote thoughts, imagery and appraisals that discourage NSSI whilst simultaneously modifying cognitions that encourage NSSI.

Emotional cascade theory and non-suicidal self-injury: the importance of imagery and positive affect

Grounded in Emotional Cascade Theory, we explored whether rumination and multisensory imagery-based cognitions moderated the relationships between affect and both odds of non-suicidal self-injury (NSSI), and frequency of the behaviour. A sample of 393 university students completed self-report questionnaires assessing the constructs of interest. Contrary to expectations, rumination did not emerge as a significant moderator of the affect-NSSI relationship. However, the relationship between affect and frequency of NSSI was moderated by the use of imagery. Further, the relationship between negative affect and NSSI was moderated by positive affect, underscoring the need to consider both negative and positive affect in models of NSSI. Most youth who self-injured reported thinking in images while the urge to self-injure was strong, with 53% thinking in images at least half the time. Future work is needed to explore how positive and negative affect work in concert to govern NSSI, and how imagery might either exacerbate or reduce risk of NSSI.

The relationship between entrapment and suicidal behavior through the lens of the integrated motivational-volitional model of suicidal behavior

Suicide and suicidal behavior are major public health concerns. As a result, a number of psychological models have been developed to better understand the emergence of suicidal ideation and suicide attempts. One such model is the integrated motivational-volitional model, a tri-partite model of suicidal behavior, which posits that entrapment is central to the final common pathway to suicide. In this review, we summarize the extant research evidence for the relationship between entrapment and suicidal ideation and behavior. Although there is robust evidence for the relationship between entrapment and suicidal ideation and behavior, there are gaps in our knowledge. We discuss the clinical implications and suggest key directions for future research.

Treatment of Intrusive Suicidal Imagery Using Eye Movements

Suicide and suicidal behavior are major public health concerns, and affect 3–9% of the population worldwide. Despite increased efforts for national suicide prevention strategies, there are still few effective interventions available for reducing suicide risk. In this article, we describe various theoretical approaches for suicide ideation and behavior, and propose to examine the possible effectiveness of a new and innovative preventive strategy. A model of suicidal intrusion (mental imagery related to suicide, also referred to as suicidal flash-forwards) is presented describing one of the assumed mechanisms in the etiology of suicide and the mechanism of therapeutic change. We provide a brief rationale for an Eye Movement Dual Task (EMDT) treatment for suicidal intrusions, describing techniques that can be used to target these suicidal mental images and thoughts to reduce overall behavior. Based on the available empirical evidence for the mechanisms of suicidal intrusions, this approach appears to be a promising new treatment to prevent suicidal behavior as it potentially targets one of the linking pins between suicidal ideation and suicidal actions.