Understanding the Roles of Communication and Psychological Pain in Suicide Through the Assessment of Consistent Self-Report and Behavioral Measure

Abstract

Background. Suicide is an enormous problem worldwide. Even after decades of dedicated research, our ability to predict and prevent this devastating behavior is limited. One major limitation to understanding suicide is the fact that suicide risk is not outwardly observable, even to expert researchers and clinicians, unless a person chooses to communicate their thoughts to others. This dissertation sought to better understand: (1) how people communicate suicidal thoughts and behaviors (STBs) across varying assessment methods, examining the impact of inconsistency in self-report on research conclusions; (2) why people consider killing themselves, focusing on the construct of psychological pain; and (3) when the signal for psychological pain is the most robust. Method. Questions were examined in two studies looking at group differences between suicide ideators and non-suicidal controls. In Study 1, participants were assessed for the presence of suicidal ideation (SI) and suicide attempt (SA) utilizing several widely-used methods: phone screen, in-person interview, self-report questionnaire, and confidential exit survey. Participants also reported on accuracy, effort, and experience/conceptualization of SI. In Study 2, psychological pain was assessed at baseline (using self-report and a novel behavioral probe discrimination task) and again following a negative mood induction. Analyses were performed with groups classified based on: specifically defined subgroups, traditional phone screen methods, and a more stringent approach requiring consistent report of study eligibility criteria (following recommendations from Study 1). Based on the importance of increasing generalizability, both studies were repeated across community and veteran samples. Results. Regarding how people communicate STBs, although participants generally were consistent in reports of SI and SA across self-report assessments, there also was a substantial degree of inconsistency, which was not explained by differences in response styles or understanding of terms. Regarding why people are suicidal, suicidal participants reported significantly greater psychological pain via self-report questionnaire, compared with non-suicidal controls. However, no group differences were observed when assessed using the novel behavioral probe discrimination task at baseline or after a negative mood induction. Regarding when the psychological pain signal is the strongest, data revealed a pattern within subgroups such that, after a negative mood induction, suicidal participants generally increased attention toward these stimuli (as hypothesized); however, contrary to hypotheses, the more recently/severely suicidal participants decreased attention toward psychological pain stimuli. Finally, the use of a more stringent classification strategy increased between-group effect sizes, but also decreased the statistical power to detect significant effects. Discussion. Results suggest the importance of classifying suicidal and control participants based on consistent reporting across multiple items, inclusive of a graded scale to capture a broad spectrum of thoughts. Additionally, more research is needed to further study the association between STBs and psychological pain, to develop objective measures for suicide risk, to account for current mood of participants at the time of assessment, and to examine STB-related communication in real-world settings. Such efforts may allow us to advance the assessment of STBs, ultimately improving the prediction and prevention of suicide.