30
Series
hopelessness scores in a 10-year prospective study of
patients admitted to hospital with suicidal ideation.
However, findings from a 12-year prospective Finnish
study
33
showed that when suicidal intent was compared
with hopelessness (in a sample of 224 cases of attempted
suicide), hopelessness was a non-significant predictor of
suicide. More recently, in a small study
34
of people who
attempted suicide, hopelessness did not significantly
predict future suicide attempts in a 4-year follow-up
when past suicide-attempt history and entrapment were
included in the analysis. These more recent mixed
findings suggest that although hopelessness is important
in the development of suicidal ideation (consistent with
theoretical models), other factors might be more useful
in the prediction of actual suicide attempts or deaths.
Impulsivity
Although impulsivity has been studied for decades, its
association with suicide risk is not as consistent or as
straightforward as originally thought, and its effect might
be less direct.
28,35
Findings from many studies
3,36,37
have
shown that self-reported impulsivity is associated with
suicidal ideation, suicide attempts, and suicide deaths.
The meaning of impulsivity is confused and needs
resolution, with some studies operationalising it as
novelty-seeking behaviour or having a short attention
span, whereas other researchers define it as non-
planning or cognitive impulsivity.
37
Other research
emphasises the importance of differentiation between
impulsivity as a trait versus a state construct.
38
The
evidence is also mixed regarding whether impulsivity is
associated with the medical seriousness of the episode.
39,40
Nonetheless, impulsivity should still be considered when
risk of suicide or self-harm is assessed. It might not be
important in all cases of suicide risk, but it is more likely
to be evident in young people than in older people.
2,41,42
Impulsivity can be useful to predict repeated
suicide
attempts in individuals with personality disorder.
43
Impulsive aggression is associated with suicide
attempts.
12,28
Negative urgency, defined as the degree to
which a person acts rashly when distressed, also needs
further research.
44
Perfectionism
Growing evidence suggests that perfectionism is
associated with suicidal ideation and suicide attempts,
although few prospective clinical studies have been
done.
45,46
Perfectionism can be defined in different ways
and not all types are equally associated with suicide risk.
One type, socially prescribed perfectionism (defined as
the belief that other people [eg, family members] hold
unrealistically high expectations of you
47
), is most
consistently associated with suicidal thoughts and
attempts, especially when these socially determined
beliefs are internalised as self-criticism. Recent research
suggests that the social dimensions of perfectionism
increase suicide risk by promoting a sense of social
disconnection,
46
which is consistent with the integrated
motivational-volitional model and interpersonal theory
of suicide. In particular, perfectionistic beliefs can also
interact with other factors (eg, negative life events,
adversity, and cognitions) to impede recovery from a
suicidal episode or increase risk of suicidal ideation and
self-harm further.
27,45,48
The big five personality dimensions: neuroticism, extroversion,
agreeableness, openness to experience, and conscientiousness
In general terms, high levels of neuroticism and low
levels of extroversion are associated with suicidal
ideation, attempts, and completions.
49–52
However,
exceptions exist; in an 18-year follow-up
53
of patients with
depression, neuroticism did not predict future suicide
risk. The combined effects of high neuroticism and low
extroversion might be stronger predictors of suicide than
is neuroticism alone.
54
The proposed interaction is
consistent with predominant theories, suggesting that
people who are more sensitive to distress (ie, high
neuroticism) and are socially disconnected (ie, low
Figure 2:
Integrated motivational-volitional model
8
of suicidal behaviour
Figure reproduced fromO’Connor
8
by permission of JohnWiley & Sons.
Pre-motivational phase
Background factors and
triggering events
Motivational phase
Ideation/intention formation
Volitional phase
Behavioural enaction
Diathesis
Environment
Life events
Defeat and
humiliation
Entrapment
Suicidal ideation
and intent
Suicidal behaviour
Examples include capability,
impulsivity, implementation,
intentions (planning), access
to means, and imitation
Threat-to-self moderators
Motivational moderators
Volitional moderators
Examples include social
problem solving, coping,
memory biases, and
ruminative processes
Examples include thwarted
belongingness,
burdensomeness, future
thoughts, goals, norms,
social support, and attitudes
+
+
1...,24,25,26,27,28,29,30,31,32,33 35,36,37,38,39,40,41,42,43,44,...56