Treatment of Intrusive Suicidal Imagery Using Eye Movements

Experience of pre-suicidal suffering: insights from suicide attempt survivors

PURPOSE

Psychache significantly contributes to the suicidal process. However, the transition from pre-suicidal suffering to a suicide crisis remains one of the least explored stages in suicidology.

METHODS

We retrospectively explored experience of pre-suicidal suffering through semi-structured, in-depth interviews with 12 individuals recruited from the Vilnius City Mental Health Center, Lithuania. Interpretative phenomenological analysis was employed to identify recurring patterns.

RESULTS

Nine primary group experiential themes emerged: Certain adverse life events occurring during the suicidal process were not immediately perceived as connected; Complex traumatic events laid the groundwork for a profound sense of lack; A compensatory mechanism balanced the experience of profound lack; Exhaustion ensued from efforts to sustain the compensatory mechanism; The main trigger directly challenged the compensatory mechanism; The affective state followed the experience of the main triggering event; Dissociation served to isolate psychache; Thoughts of suicide experienced as automatic; Suicide was perceived as a means to end suffering.

CONCLUSION

The findings suggest that the suicidal process unfolds over an extended period of suffering, culminating in a crisis to alleviate unbearable psychological pain. In clinical practice, identifying the main triggering event discussed in this study can be pivotal in understanding the essence of suffering characterized by profound lacking and developed compensatory mechanisms.

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 association between childhood maltreatment and suicidal intrusions: A cross-sectional study

Childhood maltreatment may play an important role in the transition from suicidal ideation to suicidal behavior. Recently, research has begun evaluating the association between childhood maltreatment and involuntary and distressing intrusions about one's own suicide, also called suicidal intrusions. This cross-sectional, multicenter study aimed to investigate the association between childhood maltreatment and the severity of suicidal intrusions using online questionnaires. Participants were suicidal outpatients currently receiving treatment at a Dutch mental health institution (N = 149). The Childhood Trauma Questionnaire-Short Form and Suicidal Intrusions Attributes Scale were administered online. A simple linear regression was performed followed by a multiple linear regression with backward selection to separate the predictors of childhood maltreatment subscales. Next, significant predictor variables were used to perform an additional regression analysis with gender, age, posttraumatic stress disorder (PTSD) diagnosis, and depressive symptoms as potential covariates. The results showed that childhood maltreatment was significantly associated with suicidal intrusion scores, B = .22, t(147) = 2.010, p = .046. A multiple linear regression analysis showed that the only specific form of childhood maltreatment associated with suicidal intrusions was sexual abuse; the association remained after controlling for age, gender, PTSD diagnosis and depressive symptoms, F(5, 143) = 11.15, p < .001. In summary, the present study confirms the link between childhood maltreatment, particularly childhood sexual abuse, and suicidal intrusions. This finding implies that in the treatment of suicidal intrusions and suicidality, childhood sexual abuse should be identified and targeted with evidence-based treatments for PTSD.

Defining Autonomy in Psychiatry

Mental illness undermines a patient's personal autonomy: the capacities of a person that enables them to live a meaningful life of their own making. So far there has been very little attention given to personal autonomy within psychiatry. This is unfortunate as personal autonomy is disturbed in different ways in psychiatric disorders, and understanding how autonomy is affected by mental illness is crucial for differential diagnosis and treatment, and also for understanding personal recovery. We will argue that disturbance of personal autonomy is related to patient's diminished quality of life and suffering that motivates seeking treatment. We hypothesize that (1) personal autonomy is generally reduced by mental illness but (2) the effects on autonomy are expressed differently according to the underlying psychopathology, and also vary according to the (3) context, and perspective of the individual patient. We provide a discussion of how autonomy can be affected in five prototypical mental disorders; Major Depressive Disorder, Substance-use Disorders, Obsessive Compulsive Disorder, Anorexia Nervosa and Schizophrenia. We take these disorders to be illustrative of how diminished autonomy is a central but overlooked dimension of mental illness. We will use our discussion of these disorders as the basis for identifying key dimensions of autonomy that could be relevant to innovate treatment of psychiatric disorders.

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 ).

Theoretical and empirical foundations of a novel online social networking intervention for youth suicide prevention: A conceptual review

Suicide is a major public health problem and is the second leading cause of death in young people worldwide. Indicating a lack of adequate treatment approaches, recent data suggest a rising suicide rate. Current approaches to suicide prevention do not sufficiently account for the specific needs of young people or the ways in which they engage with the health system, nor are they adequately theory-driven. In this paper, we review an empirically-supported theoretical model of suicide together with the latest evidence in treating young people who are at risk. We discuss the potential efficacy of social-media-based online interventions, with a particular focus on how they may be uniquely placed to target interpersonal risk factors for suicide. We highlight the risks associated with such interventions, including the potential for contagion to occur. Based on prominent theoretical models and gaps in existing treatment approaches, we propose a newly-developed, theory-driven, online social-networking-based intervention for suicide prevention in young people.

The implementation and adherence to evidence-based protocols for psychotherapy for depression: the perspective of therapists in Dutch specialized mental healthcare

BACKGROUND

Although psychotherapy is an effective treatment for depression, a large number of patients still do not receive care according to the protocols that are used in clinical trials. Instead, patients often receive a modified version of the original intervention. It is not clear how and when treatment protocols are used or modified in the Dutch specialized mental health care and whether these changes lead to suboptimal adherence to treatment protocols.

METHODS

In the context of an ongoing multicenter trial that investigates whether twice-weekly sessions of protocolized interpersonal psychotherapy (IPT) and cognitive behavioral therapy (CBT) for depression lead to better treatment outcomes compared to once-weekly sessions, two focus groups using semi-structured interviews were organized. Aims were to increase insight in the adherence to and modifications of CBT and IPT protocols in the Dutch specialized mental health care for depression. Participants were fifteen therapists from seven mental health locations part of five mental health organizations. Verbatim transcripts were coded and analyzed using qualitative software.

RESULTS

Three themes emerged: modification as the common practice, professional and patient factors influencing the adherence to protocols and organizational boundaries and flexibility. Treatment modification appeared to happen on a frequent basis, even in the context of a trial. Definitions of treatment modifications were multiple and varied from using intuition to flexible use of the same protocol. Therapist training and supervision, the years of work experience and individual characteristics of the therapist and the patient were mentioned to influence the adherence to protocols. Modifications of the therapists depended very much on the culture within the mental health locations, who differed in terms of the flexibility offered to therapists to choose and modify treatment protocols.

CONCLUSIONS

Not all treatment modifications were in line with existing evidence or guidelines. Regular supervision, team meetings and a shared vision were identified as crucial factors to increase adherence to treatment protocols, whereas additional organizational factors, among which a change of mindset, may facilitate adequate implementation.