Examining Patterns of Change in the Acquired Capability for Suicide Among Eating Disorder Patients

Acquired Capability for Suicide: An Evolutionary Concept Analysis

While virtually all suicide attempters experience ideations, not all who think about suicide will attempt or die by suicide. The ideation-to-action framework has led to new theories distinguishing suicide ideators from suicide attempters. The framework suggests that suicide progresses on a spectrum of thoughts and behaviors with different identifiers and explanations. The concept of acquired capability for suicide (ACS), conceptualized by the Interpersonal Psychological Theory of Suicide, is the first to explain the movement from ideation to action. This concept analysis of ACS is timely and relevant for greater clarification of the role ACS has in the movement from ideation to action. Rodgers' evolutionary concept analysis method is used. The six-step evolutionary method highlights the concept's attributes, antecedents, and consequences and provides a basis for further inquiry and development rather than a final definition.

Fluidity in capability: Longitudinal assessments of suicide capability using ecological momentary assessments

INTRODUCTION

Suicide capability is posited to facilitate the movement from ideation-to-action. Emerging evidence suggests capability comprises both trait- and state-like facets. This study examined fluctuations in and associations of acquired, dispositional, practical, and perceived capabilities, and suicidal mental imagery, and suicidal ideation.

METHOD

Seventy-five adults (48 females, Mage = 36.53 years) with lived experience of suicidal ideation and/or attempt responded to four prompts per day for 2 weeks that assessed suicide capability and suicidal ideation. Mean-squared successive differences and probability of acute change indices and multilevel models were used for analyses.

RESULTS

All facets of suicide capability fluctuated. Acquired and dispositional capabilities were trait-like, with practical and perceived capabilities being state-like. Suicidal mental imagery was the only facet of suicide capability that distinguished participants with a suicide attempt in the past 12 months from participants with a suicide attempt more than 1 year ago and suicide ideators. Suicidal mental imagery was associated with concurrent suicidal ideation and predictive of next assessment suicidal ideation.

CONCLUSION

Suicidal mental imagery may be uniquely associated with suicide capability. This study suggests there are trait- and state-like facets of capability that can combine to potentially ready an individual to engage in suicidal behaviors.

Development and Validation of the Fearlessness About Suicide Scale

Recent work has identified fearlessness about suicide, rather than fearlessness about death, as more theoretically relevant in the assessment of capability for suicide and thus a more appropriate construct of measurement. The aim of the current project was to develop and validate a scale specifically assessing fearlessness about suicide. Across two studies, support for a 7-item, single-factor structure of the Fearlessness About Suicide Scale (FSS) emerged. The FSS factor structure demonstrated a good fit in the first study and was replicated in the second study. Measurement invariance was examined across those identifying as men and women and found to be comparable. The FSS also demonstrated test-rest reliability and good convergent and divergent validity in community and undergraduate samples. Overall, findings indicate that the FSS has a replicable factor structure that generalizes across those identifying as men and women and may better assess components of capability for suicide than existing scales.

A systematic review of the relationship between death anxiety, capability for suicide, and suicidality

This systematic review aimed to examine the relationship between death anxiety and suicidality in adults, and the impact of death anxiety interventions on the capability for suicide and suicidality. MEDLINE, PsycINFO, PubMed, and Web of Science were extensively searched using purpose-related keywords from the earliest to July 29th, 2022. A total of 376 participants were included across four studies which met inclusion. Death anxiety was found to relate significantly and positively with rescue potential, and although weak, negatively with suicide intent, circumstances of attempt, and a wish to die. There was no relationship between death anxiety and lethality or risk of lethality. Further, no studies examined the effects of death anxiety interventions on the capability for suicide and suicidality. It is imperative that future research implements a more rigorous methodology to establish the relationship between death anxiety and suicidality and establish the impacts of death anxiety interventions on the capability for suicide and suicidality.

Examining the relationship between dysmorphia symptoms and suicidality through the lens of the Interpersonal Theory of Suicide

OBJECTIVE

Using the Interpersonal Theory of Suicide (IPTS) as a framework, this two-study investigation tested whether burdensomeness and low belongingness explained the association between body and muscle dysmorphia symptoms and suicidal ideation (tested in Study 1 and Study 2), and if fearlessness about death and pain tolerance explained the association between dysmorphia symptoms and previous suicide attempt frequency (tested in Study 2).

METHODS

Study 1 used a community sample (n = 273) and Study 2 used an at-risk population sample (n = 261). Participants completed cross-sectional questionnaires online.

RESULTS

In Study 1, both types of dysmorphic symptoms related to suicidal ideation through burdensomeness, but only body dysmorphic symptoms related to suicidal ideation through low belongingness. In Study 2, results were replicated as both types of dysmorphic symptoms related to suicidal ideation through burdensomeness. While both types of symptoms related to low belonging, low belonging did not relate to suicidal ideation. Neither dysmorphic symptoms nor capability for suicide related to frequency of suicide attempts.

CONCLUSIONS

Results suggest that improving interpersonal needs, such as feeling more effective, may be important treatment targets for individuals with dysmorphic symptoms who also experience suicidal ideation. Future work should continue to identify mediators for suicide attempts among individuals with dysmorphia symptoms.

Exploring the indirect effects of acute dissociation on capability and suicide risk: A multi-method investigation with augmented reality

INTRODUCTION

The current study aimed to explicate the role of dissociation in the capability and suicide relationship by examining how lifetime and state-based acute dissociation contributes to capability for suicide using a multi-method approach of self-report and augmented reality (AR) laboratory tasks.

METHOD

Participants (N = 145) were students recruited for course credit at a southern university. Participants completed self-report and laboratory AR dissociative induction tasks. Correlations and mediation analyses were conducted to test hypotheses using SPSS v. 26 and PROCESS Macro.

RESULTS

There was a significant indirect effect on capability and suicidal ideation via acute dissociation (β = 0.035, SE = 0.02, 95% CI = 0.001, 0.095). Additionally, there was a significant indirect effect on capability and suicide attempt(s) via dissociation (β = 0.19, SE = 0.10, 95% CI = 0.044, 0.449).

CONCLUSIONS

As prior theories suggest, dissociation may augment feeling disconnected from the body and may temporarily impact capability to render a suicidal act as more probable. The presence of dissociation after a painful and provocative attempt may increase capability and pain tolerance. Implications of these findings include the consideration of dissociation as a pertinent factor in the assessment and treatment of suicide and the role of AR in aiding the exploration of suicide correlates.

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.

Dynamic associations between interpersonal needs and suicidal ideation in a sample of individuals with eating disorders

BACKGROUND

Over half of individuals with eating disorders experience suicidal ideation at some point in their lives, yet few longitudinal studies have examined predictors of ideation in this at-risk group. Moreover, prospective research has focused on relatively distal or trait-level factors that are informative for distinguishing who is most at risk but not when. Little is known about more proximal or state-level risk factors that fluctuate within an individual, which is critical for determining when a person is most likely to engage in suicidal behaviors.

METHODS

Women (N = 97) receiving treatment for their eating disorder completed questionnaires weekly to assess suicidal ideation and interpersonal constructs (i.e. perceived burdensomeness, thwarted belongingness) theorized to be proximal predictors of suicidal desire. Longitudinal multilevel models were conducted to examine both within- and between-person predictors of suicidal ideation across 12 weeks of treatment.

RESULTS

Statistically significant within-person effects for burdensomeness (β = 0.06; p < 0.001) indicate that when individuals have greater feelings of burdensomeness compared to their own average, they also experience higher suicidal ideation. We did not find any significant influence of thwarted belongingness or the interaction between burdensomeness and belongingness on suicidal ideation.

CONCLUSIONS

This study was the first to examine dynamic associations between interpersonal constructs and suicidal ideation in individuals with eating disorders. Results are only partially consistent with the Interpersonal Theory of Suicide and suggest that short-term changes in burdensomeness may impact suicidal behavior in individuals with eating disorders.

Examining the temporal stability of suicide capability among undergraduates: A latent growth analysis

BACKGROUND

Relatively few studies test the interpersonal psychological theory's monotonicity hypothesis. The monotonicity hypothesis proposes that suicide capability (i.e., fearlessness about death and pain tolerance) is stable or increases linearly with exposure to painful and provocative events. Research is conflicted, suggesting that suicide capability is static, decreases, or increases and returns to baseline. The current study thus tested this hypothesis in a sample of college students with histories of suicidal ideation. We hypothesized a stable and an increasing trajectory.

METHODS

Participants were 206 undergraduates; primarily women (73%), on average 19.05 years old, heterosexual (85%), and first-years (69%). Participants completed a baseline battery of questionnaires on suicide risk factors and daily diaries on suicide capability and suicidal ideation for 90 days (n = 7,342 surveys, 40% compliance rate). Group-based trajectory analyses were conducted with the SAS macro PROC TRAJ.

RESULTS

Modeling revealed a three group quadratic model.  Low (27.7%), Moderate (41.3%), and High (31.1%) suicide capability groups remained static over time. Baseline suicidal ideation, but not history of suicide attempts or family history of suicidal behavior, distinguished groups; participants with suicidal ideation at baseline were less likely to be in the low suicide capability group.

LIMITATIONS

Brief, dichotomized assessments, and a high attrition rate.

CONCLUSIONS

These data showed temporal stability of suicide capability and suggest that the "acquired" component of capability may be overemphasized. Clarifying the stability and modifiability of suicide capability will enable empirically-based applications of the theory to suicide prevention.

The Interpersonal-Psychological Theory of Suicide to Explain Suicidal Risk in Eating Disorders: A Mini-Review

Suicide is a major cause of death in Eating Disorders (EDs) and particularly in anorexia nervosa (AN). The aim of the present mini-review was to summarize the literature focusing on the interpersonal-psychological theory of suicide (IPTS) by Thomas E. Joiner, as applied to explain suicidal risk in EDs. PubMed database was used to search articles focused on IPTS in EDs; 10 studies were eventually included. The majority of the included studies reported data from the same sample, even though the hypotheses and analyses for each study were unique. The investigated suicidal outcomes were suicidal ideation (SI) (40%), non-suicidal self-injury (10%), suicide attempt (40%) and suicide (10%). In ED patients Perceived Burdensomeness (PB) may play an important role, especially regarding SI risk. ED patients may feel like a burden to their close ones, and actually some of the ED symptoms may be an expression of anger and hate against the self. Overall, currently available research has supported some IPTS derived predictions (i.e., ED symptoms may increase PB and thereby SI), but not others (i.e., the elevated suicide rate in AN may be due to higher acquired capability for suicide). Further research on IPTS tenets as well as on other theoretical perspectives and constructs (e.g., interoceptive awareness), hopefully with a longitudinal design and adequate follow-up duration, might allow a more thorough understanding of the complex topic of suicidal behavior in ED patients.

ADAPTED TO FEAR: FEARLESSNESS ABOUT DEATH IS ASSOCIATED WITH HEART RATE VARIABILITY

Objective: Capability for suicide, which refers to an individual's ability to enact potentially lethal harm to oneself and overcome the fear of dying, is an empirically supported component of the Interpersonal-Psychological Theory of Suicide. Although an abundance of research has examined capability for suicide through the use of self-report data, little research has assessed specific psychophysiological mechanisms that may contribute to capability for suicide. We assessed relationships between capability for suicide (fearlessness about death and pain tolerance), high frequency heart rate variability (HF HRV), and subjectively reported fear during a death related event. Given that greater HRV is associated with calmness and lack of distress, we predicted that HRV during a fearful event would be positively associated with the capability for suicide.

Method: Data were collected from 101 undergraduates. Participants self-reported fearlessness about death and had their pain tolerance assessed with an algometer. HF HRV was assessed prior to, during, and following a film-viewing task designed to elicit fear of death.

Results: Correlations revealed that fearlessness about death was negatively associated with self-reported fear during the film viewing and positively associated with self-reported and objective pain tolerance. Linear regressions found that fearlessness about death, but not self-reported or objective pain tolerance, was positively associated with HF HRV during the film-viewing and recovery.

Discussion: During a fearful, death related event, greater HF HRV was associated with greater fearlessness about death, suggesting that HF HRV may represent one possible mechanism through which fearlessness about death is maintained.

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.