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Suicide Prevention and Intervention: Summary of a Workshop (2001)

Chapter: Cognitive Approaches to Suicide

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Suggested Citation:"Cognitive Approaches to Suicide." Institute of Medicine. 2001. Suicide Prevention and Intervention: Summary of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/10226.
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could discourage the media from addressing suicide in any way. She stated that the media should be given positive examples of stories done well as models to follow.

Dr. Gould listed the following specific guidelines for media coverage of suicide.

(1) Consider whether the suicide in question is newsworthy. (2) Do not misrepresent suicide as a mysterious act by an otherwise healthy or high-achieving person. (3) Do not present suicide as a reasonable or understandable way of problem solving. (4) Include information that suicide in an uncommon, but fatal complication of mental and/or substance abuse disorders, which are treatable. (5) Include information that suicide can be prevented with appropriate treatment. (6) Exercise care when using pictures of victims, since it remains unknown if pictures increase contagion. (7) Do not provide a detailed description of method. Evidence shows that when enough details are given, vulnerable youths will commit suicide in the same spot and/or with the same methods. (8) Limit the prominence, length, and number of stories. (9) Edit headlines to match and not sensationalize the story. (10) Provide local treatment resources with each story. Dr. Kalafat suggested that the media is just one part of the “competent community” and should be included in the community collaborative.

Internet. Dr. Gould briefly discussed the possible influence of internet content and chat rooms on fostering suicide contagion. She mentioned research on help-seeking behavior demonstrating that adolescents are likely to look to the internet for help with problem solving. This provides an opportunity for contagion to occur, as well as a point of intervention and prevention efforts.

Suicide Clusters. Dr. Gould provided a brief discussion of suicide clusters through the mechanism of contagion. The first generation of research on clusters consisted of descriptive studies looking at specific clusters in various groups, including religious sects, psychiatric inpatient wards, and high schools students. These anecdotal case reports were difficult to interpret or draw conclusions from. The next wave of studies used statistical approaches to test for clusters. As Dr. Gould described, these generally showed that clusters did occur, primarily among teenagers and young adults. Case-controlled psychological autopsy studies are one way to examine why clusters occur. Dr. Gould reports that very little research has been completed in this area, although some studies are currently underway to address these gaps.

Dr. Gould concluded by emphasizing that the development and implementation of media guidelines and strategies to prevent clusters are just one part of the overall model for suicide prevention, a necessary part of a competent community. Major risk factors for suicide, whether psychiatric disorders, biological factors, or the impact of stressful events, must be attended to as an essential part of any suicide prevention strategy. Underlying vulnerabilities are what allow contagion to facilitate the route to suicide in certain individuals.

COGNITIVE APPROACHES TO SUICIDE

Dr. Aaron T.Beck discussed four topics: (1) an overview of nomenclature and measurement of suicidality, (2) thought (cognitive) disturbances associated with suicidality, (3) how suicidal behaviors differ across psychiatric diagnoses, and (4) data from an ongoing prospective suicide

Suggested Citation:"Cognitive Approaches to Suicide." Institute of Medicine. 2001. Suicide Prevention and Intervention: Summary of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/10226.
×

prevention study at the University of Pennsylvania. He discussed data from his career in cognitive behavioral therapy and suicide research showing suicide can be reduced by changing unhealthy habits of thought (cognitions).

The patients who ultimately committed suicide seemed to be among those who were the most hopeless.

Aaron T.Beck

Approximately 30 years ago, Dr. Beck and his colleagues developed the first nomenclature for suicidal behaviors, distinguishing contemplating suicide (suicide ideation), from attempting (but not committing suicide), from committing (completing) suicide. Dr. Beck described instruments they developed to measure characteristics of suicidal behavior, including the degree of intent to kill oneself, suicidal ideations, and the medical lethality of attempts. Dr. Beck reported that suicidal ideation and intent scores did not correlate highly with the medical lethality of attempts. However, Dr. Beck found that the person’s belief in the lethality of the method was significantly correlated with intent. Out of this early work, Dr. Beck and his colleagues developed two additional scales: The Beck Hopelessness Scale and The Beck Depression Inventory. According to Dr. Beck, The Hopelessness Scale “was a very good predictor of ultimate suicide.”

In addition to the emotional disturbances in psychiatric disorders, there are abnormalities in thinking and reasoning, collectively called cognitive disturbances. Dr. Beck described two types of cognitive disturbances observed in suicidal people. There are cognitive disturbances that occur for brief periods of time and resolve when other symptoms of the psychiatric disorder diminish. These are referred to as “state” cognitive disturbances. Trait cognitive disturbances are those which remain relatively constant, even when other symptoms have diminished or resolved. Dr. Beck found that hopelessness—unwavering pessimism even in the face of contrary evidence—is one such cognitive distortion expressed both in state and trait forms in suicidal people. He also found that state hopelessness is more often associated with suicidality in people with borderline personality disorder, and that trait hopelessness is more frequently associated with depressive disorders.

Our theory is that the [borderline] patients learned enough in therapy so that when they got out, they were able to deal better with their fear of abandonment

Aaron T.Beck

Dr. Beck described findings of past and current studies of his and his collaborators. These studies included psychiatric inpatient and outpatient populations. Dr. Beck reported robust differences in suicide rate and clinical course of suicidal behaviors depending on the diagnosis of borderline personality disorder. In a prospective study of patients admitted to a hospital emergency room for a suicide attempt, Dr. Beck found that a diagnosis of personality disorder was

Suggested Citation:"Cognitive Approaches to Suicide." Institute of Medicine. 2001. Suicide Prevention and Intervention: Summary of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/10226.
×

associated with an 8.2% risk of suicide during 5 years of follow-up, as compared to 4.6% in those diagnosed with depression with no personality disorder. He also noted that approximately 99% of those who attempted suicide during the follow-up period of this study, qualified as having an affective disorder at the time, including those diagnosed with a personality disorder. As described by Dr. Beck, the clinical hallmark of borderline personality disorder is emotional volatility in response to minimal, or perceived, environmental stimuli, with heightened sensitivity to abandonment. Emotional modulation, inhibition, controls, and coping skills are inadequate in these patients. They are not able to maintain normal mood states (euthymia), in other words not depressed, nor excessively elated. They experience little or no control over their depressive and suicidal feelings. Eighty percent of the people with borderline personality disorder in the study also had substance abuse problems, as opposed to 65% of those people who did not have this diagnosis.

Learning the problem solving methods is a kind of an antidote to this trait-like hopelessness.

Aaron T.Beck

Dr. Beck reported that in people with personality disorders, suicide occurred at times of acute distress. He reported that cognitive therapy significantly reduces suicides and suicide attempts in patients with borderline personality disorder. As little as 10 weeks of therapy was effective. Some of the therapeutic effect occurs after the cessation of the therapy sessions, during follow-up, which involves lower frequency, briefer, and less interpersonally intensive clinic appointments. The conference attendees discussed possible mechanisms for the continued efficacy after therapy sessions ended, including generalization of learned coping skills to more life-situations over time, or reduction in dependence when therapy ends.

Risk for suicide with depression shows a different clinical course, compared with borderline personality disorder. According to Dr. Beck, suicide attempts associated with depression occur during periods of severe depressive symptoms. These periods of severe depression are associated with profound hopelessness and generalized cognitive distortions. Those who survive a suicide attempt can recover form the depression and achieve an euthymic state again, although the hopelessness persists for some of these individuals. Cognitive therapy, Dr. Beck reports, significantly reduces hopelessness and was more effective than imipramine (an antidepressant medication). Dr. Beck also reported that cognitive therapy “has a significant impact on suicide ideation, as well as hopelessness, as compared to placebo.” A number of studies in more than one country, according to Dr. Beck, show that cognitive problem-solving techniques significantly reduce the rate of suicide attempts per month, and delay the time period to next attempt.

In summary, according to Dr. Beck, cognitive therapy is effective in reducing suicidal behaviors in two disorders, borderline personality disorder and depressive disorder. Suicidal behaviors in both of these disorders is associated with hopelessness and cognitive distortions. The reduction in suicide, according to Dr. Beck, is mediated through remedying the cognitive distortions and/or learning coping skills to reduce their negative effects.

Suggested Citation:"Cognitive Approaches to Suicide." Institute of Medicine. 2001. Suicide Prevention and Intervention: Summary of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/10226.
×
Page 10
Suggested Citation:"Cognitive Approaches to Suicide." Institute of Medicine. 2001. Suicide Prevention and Intervention: Summary of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/10226.
×
Page 11
Suggested Citation:"Cognitive Approaches to Suicide." Institute of Medicine. 2001. Suicide Prevention and Intervention: Summary of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/10226.
×
Page 12
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For many, thoughts of suicide are abundant and frequent. There exists a fear of death but an even greater fear of life due to the latter's hardships. Participants of the committee on the Pathophysiology and Prevention of Adult and Adolescent Suicide of the Institute of Medicine's workshop on suicide prevention; however, believe that there is potential for better suicide prevention. Two workshops were convened by the committee: Risk Factors for Suicide, March 14, 2001 and Suicide Prevention and Intervention, May 14, 2001. The two workshops were designed to allow invited presenters to share with the committee and other workshop participants their particular expertise in suicide, and to discuss and examine the existing knowledge base.

Participants of the second workshop were selected to represent many areas including: design and analysis of prevention programs, suicide contagion, and firearm availability and suicide. The committee wanted to assess the science base of suicide etiology, evaluate the current status of suicide prevention, and examine current strategies for the study of suicide. Suicide Prevention and Intervention: Summary of a Workshop summarizes the major themes that arose during the workshop. It also includes the workshop agenda and a list of speakers that were present.

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