Cognitive Risk Factors In Suicide

Research on suicide risk was a natural outgrowth of Beck's depression research, and his prospective studies have contributed to the understanding of psychological processes in suicide, particularly the role of hopelessness in predicting suicide. Hopelessness is conceived of as a relatively stable schema, incorporating negative expectations of the future.

Other researchers have identified additional cognitive risk factors for suicide that emerge even with the level of depression and degree of pathology controlled. They are low self-concept, dysfunctional assumptions, the absence of positive beliefs or reasons for living, cognitive rigidity, and poor problem-solving skills. The last two risk factors, cognitive rigidity and poor problem-solving skills, have received attention recently because of their pervasiveness in psychological disorders. Two examples of cognitive rigidity are dichotomous thinking and perfectionism. Evidence for the relationship between all-or-nothing thinking and suicidal behavior is long-standing. In addition, di-chotomous thinking is found in a range of psychological disorders, including personality disorders. It is also characteristic of the thinking of normal adolescents.

Recent research also indicates a relationship between perfectionism and suicide risk. Among inpa-tients, for example, a perfectionistic attitude toward the self and sensitivity to social criticism have been found to be associated with suicide ideation independent of depression and hopelessness. Other research has found that a certain type of perfectionism—perceived expectations for the individual by society—is related to suicide ideation. The belief that the world

Cognitive Therapy holds unrealistic and unbending expectations for an individual represents a component of the cognitive triad, the negative view of the world.

Perfectionism may generally inhibit healthy functioning. Analysis of the data from the Treatment of Depression Collaborative Study, which compared the efficacies of pharmacotherapy, cognitive therapy, and interpersonal therapy, found that subjects who had perfectionistic attitudes had a significantly negative relationship to therapeutic outcome, regardless of the type of treatment modality they received. In contrast, subjects with relatively low levels of perfectionism were responsive to all forms of intervention. Perfectionism may be thought of as a risk factor for depression and suicide, and as a challenge to psychotherapy in general.

Problem-solving deficits are of interest not only because of their demonstrated relationships to depression and suicide, but also because social problemsolving is an important skill in general adjustment. Problem solving is being taught in schools as a way to reduce conflict and promote mental health.

Problem-solving deficits have been found in suicidal children, adolescents, and adults, and these deficits become compounded as problems become interpersonal in nature. Suicidal persons have difficulty accepting problems as a normal part of life and are not inclined to engage in problem solving. Once they engage in problem solving, their solutions show more avoidance, more negative affect, less relevance, less versatility, and less reference to the future than do the solutions of nonsuicidal persons.

An important aspect of problem solving among suicide ideators appears to be a tendency to focus on the potential negative consequences of implementing any solution. This feature reflects how pessimism affects motivation in depression and is congruent with the theory of helplessness depression.

A number of researchers have constructed and tested models of how various suicide risk factors might interact. It appears that hopelessness, problemsolving skills, and self-concept are independent risk factors. Beck's observations of patients hospitalized for suicidal ideation shed some light on how self-concept, problem-solving skills, and hopelessness may appear statelike for some patients and traitlike for others. One group studied was composed of depressed persons. Their hopelessness, suicidal ideation, self-concept, and problem-solving abilities improved when their depression remitted. The second group was composed of patients with alcoholism, personality disorders, and antisocial behavior problems. Their negative views of themselves were reinforced by society. This group was characterized by cognitive rigidity, impulsivity, and poor problem-solving skills, which persisted between suicidal crises. Indeed, these characteristics may have predisposed these patients to future suicidal episodes. Thus, for some, poor problemsolving is temporary; for others, it is more chronic. It appears that once suicide becomes an alternative, restricted problem-solving ability can establish it as a stereotyped response in a very limited behavioral repertoire.

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