Reexamining the Mental Pain-Suicidality Link in Adolescence: The Role of Tolerance for Mental Pain.

OBJECTIVE: In this study, we reexamine the mental pain-suicidality link in adolescence, by focusing on mental pain tolerance as a critical factor in explaining youth suicidal behavior. METHOD: In a series of three studies, participants completed measures of mental pain (tolerance and intensity), emotional regulation, depression, and suicidality. Study 1 included a nonclinical sample of 183 Israeli adolescents. Study 2 included a nonclinical sample of 139 Israeli adolescents, who completed additional measures of self-esteem, optimism, mindfulness, meaning in life, positive affectivity, and life satisfaction. Study 3 included suicidal psychiatric inpatients (N = 24), nonsuicidal psychiatric inpatients (N = 24), and nonclinical adolescents (N = 24). RESULTS: In Study 1, mental pain tolerance was significantly associated with depression, suicidality, and emotion-regulation skills. In Study 2, mental pain tolerance was significantly associated with measures of psychological resources. In Study 3, we found that suicidal psychiatric inpatients reported significantly lower levels of mental pain tolerance than nonsuicidal psychiatric inpatients and nonclinical adolescents. No significant group difference was found in the reported intensity of mental pain. CONCLUSIONS: Findings imply that mental pain tolerance may be a better indicator for suicidal behavior during adolescence than reported pain intensity.

Mental Pain and Suicidal Tendencies in Sexual and Physical Abuse Victims.

We examine differential effects of mental pain and suicidal tendencies in female victims who have been sexually and physically abused, hypothesizing that sexual abuse victims report more mental pain and suicidal tendencies than physical abuse victims. A group of 98 women completed questionnaires that measured mental pain, suicidal tendencies and thoughts, and demographic details. Sexual abuse victims suffered more mental pain than physical abuse victims while the physical abuse victims demonstrated more repulsion by life than sexual abuse victims. Only sexual abuse victims demonstrated less attraction to life and only physical abuse victims showed more attraction to death.

Mental pain as a mediator of suicidal tendency: a path analysis.

BACKGROUND: This study used path-analysis to examine the assumption that the presence of mental pain in adults mediates the relationship between self-destruction, number of losses experienced in one's life, and suicidal tendency. METHODS: Fifty suicidal inpatients, 50 non-suicidal inpatients and 50 healthy volunteers were assessed for self-destruction, losses experienced, depression, suicidal tendency, and mental pain. RESULTS: Self-destruction was found to have both a direct effect on suicidal tendency as well as one mediated by the presence of mental pain. Number of losses effected suicidal tendency only indirectly, mediated by the presence of mental pain. Overall, self-destruction was a more significant determinant of suicidal tendency than were the number of losses experienced during one's life. A competing model, with depression replacing mental pain as the mediator, was also found to fit the data. DISCUSSION: These findings provide evidence that the presence of mental pain is a mediator in the relationships between both self-destruction and number of losses experienced, and between suicidal tendencies. More studies are needed in order to further differentiate between mental pain and depression as mediators in suicidal tendency.

Attitudes toward life and death and suicidality among inpatient female adolescents with eating disorders.

This study investigated whether attitudes about life and death are associated with suicidal behavior in eating disorders (EDs). We examined 43 nonsuicidal inpatients with EDs, 32 inpatients with EDs who attempted suicide, and 21 control participants with scales assessing attitudes to life and death, body-related attitudes, core ED symptoms, depression, and anxiety. Both ED groups showed less attraction to life and more repulsion from life than did the control participants. The suicide attempters showed greater attraction to death, less repulsion from death, and more negative attitudes toward their body than did the nonsuicidal ED and control participants. Fear of life was associated with elevated depression, body-related problems, and childhood sexual abuse. Pathological attitudes toward death were associated with greater depression and body-related problems. Suicide attempts were found in the inpatients with EDs showing binge/purge ED pathology and maladaptive attitudes toward death. This study suggests that whereas fear of life is a core feature of an ED, maladaptive attitudes toward death appear only in ED patients who have attempted suicide.

Body image among victims of sexual and physical abuse.

This study tries to understand the differences in body experience between victims of sexual abuse and physical abuse. Ninety-eight women completed questionnaires that measured personal information, body-image aberration, body sensitivity and control, and body investment. Findings indicated that victims of sexual abuse demonstrate less body maintenance and protection in addition to greater injury to body sensitivity and control than victims of physical abuse. Moreover, comparing victims of sexual abuse to physical abuse, findings revealed that only victims of sexual abuse report body-image aberrations. Thus, sexual and physical abuse should be addressed discretely because each has differential effects on bodily attitudes of victims.

Protective factors and suicidality in members of Arab kindred.

BACKGROUND: Relatively little is known about the role of protective factors in an Arab population in the presence of suicidal risk factors. AIMS: To examine the role of protective factors in a subsample of in large Arab Kindred participants in the presence of suicidal risk factors. METHODS: We assessed protective and risk factors in a sample of 64 participants (16 suicidal and 48 nonsuicidal) between 15 and 55 years of age, using a comprehensive structured psychiatric interview, the Composite International Diagnostic Interview (CIDI), self-reported depression, anxiety, hopelessness, impulsivity, hostility, and suicidal behavior in first-degree and second-relatives. We also used the Religiosity Questionnaire and suicide attitude (SUIATT) and multidimensional perceived support scale. RESULTS: Suicidal as opposed to nonsuicidal participants were more likely to have a lifetime history of major depressive disorder (MDD) (68.8% vs. 22.9% χ2=11.17, p=.001), an anxiety disorder (87.5% vs. 22.9, χ2=21.02, p<.001), or posttraumatic stress disorder (PTSD) (25% vs. 0.0%, Fisher's, p=.003). Individuals who are otherwise at high risk for suicidality have a much lower risk when they experience higher perceived social support (3.31±1.36 vs. 4.96±1.40, t=4.10, df=62, p<.001), and they have the view that suicide is somehow unacceptable (1.83±.10 vs. 1.89±.07, t=2.76, df=60, p=.008). CONCLUSIONS: Taken together with other studies, these data suggest that the augmentation of protective factors could play a very important role in the prevention of incidental and recurrent suicidal behavior in Arab populations, where suicidal behavior in increasing rapidly.

Risk factors for suicide attempt in an Arab kindred.

OBJECTIVE: This explorative study examines correlates of suicidal behavior in an extended Arab kindred selected because of a high rate of suicidal behavior. METHODS: Family members (n=468) aged 15 through 55 were assessed using a comprehensive structured psychiatric interview, the Composite International Diagnostic Interview (CIDI), which covers a wide range of psychopathology, including a spectrum of suicidal thoughts and behaviors. In addition, self-reported depression, anxiety, hopelessness, impulsivity and hostility, early childhood adversity, and suicidal behavior in first- and second-degree relatives were assessed. RESULTS: Significant associations were found between suicidal thoughts and behavior, and the presence of family history of suicide, all forms of psychopathology and suicidal behaviors. In addition, impulsivity and hostility were also significantly associated with suicidality. LIMITATION: The absence of similar assessments in comparison families, makes it difficult to assess why this family appears to be at higher risk for suicidal behavior. CONCLUSION: Risk correlates of suicidal behavior in the Arab kindred are similar to those reported from other parts of the world. These findings suggest that effective means of suicide prevention used in European populations may be successfully adapted to prevent suicide in this ethnic group as well. Since all forms of suicidal behavior in this population as well as in other Arab populations are increasing rapidly (Karam et al., 2008), these results have important implications for suicide prevention as well as for the understanding of the genetics of suicide.

An in-session exploration of ruptures in working alliance and their associations with clients' core conflictual relationship themes, alliance-related discourse, and clients' postsession evaluations.

This exploratory study examined (a) the relationship among the occurrence of ruptures in the working alliance, the emergence of client's core conflictual relationship themes (CCRT), and focus of discourse within therapeutic sessions and (b) the relationship between ruptures in the working alliance and client's postsession evaluations of session's smoothness and depth. The authors included 151 sessions from five therapies conducted in a student counseling center. Sessions were content analyzed by independent raters, and a self-report questionnaire was given to clients after each session. Ruptures were positively related to the emergence of clients' CCRT during the session, but only when the therapist was addressed as the "other." Sessions with ruptures were characterized by heightened discussion of working alliance components and were evaluated as less smooth than sessions without ruptures. Findings are discussed, and the importance of ruptures in working alliance for therapeutic change is emphasized.

Quality of depression among suicidal inpatient youth.

This study examined the relationship between suicidality and dependent and self-critical depression among adolescents. Ninety-six adolescents participated: 32 suicidal inpatients, 32 nonsuicidal inpatients and 32 healthy controls. The groups were matched for gender, age and education. Participants completed the Depressive Experience Questionnaire for Adolescents (DEQ-A), the Cognition Checklist (CCL), and the Multi-Attitude Suicidal Tendencies Scale (MAST). Results indicated that suicidal adolescents have significantly higher levels of self-critical and dependent depression, compared to nonsuicidal inpatients and healthy controls. The distinctive quality of depression among suicidal adolescents suggests assessment and treatment strategies for these individuals.

Autobiographical memory, interpersonal problem solving, and suicidal behavior in adolescent inpatients.

OBJECTIVE: The aim of the study was to test Williams' (Williams JMG. Depression and the specificity of autobiographical memory. In: Rubin D, ed. Remembering Our Past: Studies in Autobiographical Memory. London: Cambridge University Press; 1996:244-267.) theory of suicidal behavior in adolescents and young adults by examining the relationship among suicidal behaviors, defective ability to retrieve specific autobiographical memories, impaired interpersonal problem solving, negative life events, repression, and hopelessness. METHODS: Twenty-five suicidal adolescent and young adult inpatients (16.5 y +/- 2.5) were compared with 25 nonsuicidal adolescent and young adult inpatients (16.5 y +/- 2.5) and 25 healthy controls. Autobiographical memory was tested by a word association test; problem solving by the means-ends problem solving technique; negative life events by the Coddington scale; repression by the Life Style Index; hopelessness by the Beck scale; suicidal risk by the Plutchik scale, and suicide attempt by clinical history. RESULTS: Impairment in the ability to produce specific autobiographical memories, difficulties with interpersonal problem solving, negative life events, and repression were all associated with hopelessness and suicidal behavior. There were significant correlations among all the variables except for repression and negative life events. CONCLUSIONS: These findings support Williams' notion that generalized autobiographical memory is associated with deficits in interpersonal problem solving, negative life events, hopelessness, and suicidal behavior. The finding that defects in autobiographical memory are associated with suicidal behavior in adolescents and young adults may lead to improvements in the techniques of cognitive behavioral therapy in this age group.

Self-object differentiation in suicidal adolescents.

BACKGROUND: Although problems in the differentiation between self and object are commonly encountered in clinical work with suicidal adolescents, empirical validation of this phenomenon is limited in the literature. The aim of this study was to use empirical methods to examine the differentiation between self and parental representations in suicidal inpatient adolescents. METHODS: Ninety-six adolescents participated in the study: 32 suicidal inpatients, 32 nonsuicidal inpatients, and 32 healthy controls. The 3 groups were matched for sex, age, and education. All participants completed scales on self-object differentiation and suicidal tendencies. RESULTS: Suicidal adolescents were found to be significantly different from both nonsuicidal psychiatric and healthy controls in negative self and parental descriptions (P < .001) but did not differ from the other groups when describing positive traits. Moreover, suicidal adolescents described themselves as being significantly less differentiated from both their father (P < .001) and mother (P < .01) in negative traits but not in positive traits, when compared to the 2 other groups. CONCLUSIONS: Suicidal adolescents have difficulties differentiating the negative aspects of the self from the negative aspects of their parents. These results emphasize the importance of object relations theory in understanding suicidal tendencies in adolescents. A model combining negative symbiosis and suicidal tendencies offers several therapeutic intervention strategies.

Self-destructive processes and suicide.

This paper focuses on theoretical, empirical and clinical accounts of self-destructive processes in the general population, with a particular focus on suicidal individuals. The theoretical perspective includes views on self-destruction as (A) a motivated wish or need, (B) an outcome of emotional distress, (C) an outcome of distorted cognitions, and (D) as a general personality feature. The different principles of destructive operations that are inherent in each of the theoretical propositions are delineated. Examination of the empirical data reveals that various self-destructive processes described in theory are involved in suicidal behavior. The case studies demonstrate how the various self-destructive processes lead to suicidal behavior. These studies also show that in each individual case, there is more than one self-destructive process at work. It is suggested that suicidal behavior does not only evolve from external pressure and negative life events; rather, self-destructive tendencies may produce unbearable mental pain that culminates in suicidal behavior.

Negative bodily self in suicide attempters.

In the present study we investigated the relationship between suicidal behavior and aspects of bodily perception and parental care. Measures of bodily perception included measures of tactile sensitivity, body attitudes, and body experiences. Measures of parental care included parental bonding, negative and positive touch, and early maltreatment. One hundred and two adolescents (suicidal and nonsuicidal inpatients, and a control group) participated in the study. It was hypothesized that suicidal adolescents would (1) have higher tactile sensation thresholds, and more negative body attitudes and experiences; and (2) report less parental care, lower positive and higher negative parental touch, and higher parental maltreatment. It was also hypothesized that bodily sensitivity would mediate the relationship between suicidal tendencies and perceived negative early care. These hypotheses were confirmed. The role of a negative bodily self in suicidal behavior is proposed and discussed.

Self complexity of suicidal adolescents.

UNLABELLED: This study examined the positive and negative self-complexity of suicidal adolescents. METHODS: Thirty-two Israeli suicidal inpatients, thirty-two nonsuicidal inpatients and thirty-two control participants completed scales on self-complexity and suicidal tendencies. Self-complexity was based on Linville's measure and revealed four different aspects of self-complexity: number of positive/negative traits, number of positive/negative/neutral self-aspects, amount of redundancy of the positive/negative traits and subjective similarity between each two self-aspects. RESULTS: In comparison with both psychiatric and control, the suicidal self was characterized by the highest number of negative traits and negative self-aspects. In comparison with control, the suicidal self was characterized by the highest number of positive categories and the lowest number of neutral categories and redundancy in the positive traits. No significant differences were found between the suicidal and the psychiatric in the number of positive and neutral self-aspects and in the level of redundancy of the positive traits. After Bonferroni post-hoc correction for multiple testing, the effects for the number of negative traits (F = 28.53; p < .001), the number of negative self-aspects (F = 15.59; p < .001) and the number of neutral self-aspects (F = 28.14;p < .001) were still significant. CONCLUSIONS: The suicidal self is characterized by flooding of the negative aspects and a high differentiation of the positive ones. The suicidal self should be taken into consideration in both assessment and treatment of adolescents suicidality.

Terror suicide: how is it possible?

How it is possible for people who apparently do not suffer from distress or pathology to commit violent, cruel suicides? Based on the distinction between causes for suicide and facilitators of suicide, I contend that terror suicide is based largely on processes that facilitate suicide rather than on personal distress. Under this premise, terror suicides are examined in terms of enthusiastic determination to achieve a goal, ideological rage, glorification of the post self, heavenly rewards, materialistic benefits for families, induced dissociative processes, and linguistic mediation. Also described are the processes and preparations by which the idea of terror suicide and its facilitators are induced. Further, a theoretically inferred profile of the suicide attacker is also suggested.

Mental pain and suicide.

Different models of mental pain (emotional pain, psychological pain, psychache) are described: (A) the literary model that is based on a content analysis of Styron's book Darkness visible: A memoir of madness, describes mental pain as an inner turmoil of hostile forces; (B) the narrative model based on a qualitative analysis of pain narratives by patients defines pain as a sense of brokenness (Bolger); (C) the phenomenological-psychache model focuses on psychache as a frustration of the most important needs (Shneidman); (D) the theoretical model and (E) the empirical model view mental pain as a perception of negative changes in the self and its function (Baumeister) (Orbach & Mikulincer). The common aspects in all models include intense negative emotions, loss of self, surfeit of the negative. Other aspects appear in some of the models, but not in others (e.g., incompleteness, emptiness). The relevance of mental pain to treatment of suicidal people is discussed.

Mental pain: a multidimensional operationalization and definition.

An operationalization of mental pain is presented in three studies. The first study describes the operationalization of mental pain and the factor structure of the items produced by a content analysis of self-reports yielding a scale with nine factors: the experience of irreversibility, loss of control, narcissistic wounds, emotional flooding, freezing, estrangement, confusion, social distancing, and emptiness. Study 2 tested the relationship between mental pain and depression and anxiety in a normal population. Study 3 focused on the relationship between mental pain and coping. Mental pain is conceptualized as a perception of negative changes in the self and its functions that are accompanied by negative feelings. It is suggested that it can be meaningfully applied to the study of different mental states, life conditions, and transitions in life.

Mental pain and its relationship to suicidality and life meaning.

Shneidman (1996) proposed that intense mental pain is related to suicide. Relatedly, Frankl (1963) argued that the loss of life's meaning is related to intense mental pain. The first goal of this research was to test Shneidman's proposition by comparing the mental pain of suicidal and nonsuicidal individuals. Meaning in life and optimism are the polar opposites of suicidality and hopelessness, and the examination of these variables in relation to mental pain was undertaken to provide a test of Frankl's proposition. In two studies, a relationship between a newly developed measure of mental pain--the Orbach & Mikulincer Mental Pain Scale, 2002 (OMMP; see also Orbach, Mikulincer, Sirota & Gilboa-Schechtman, 2002)--and suicidal behavior and life meaning were examined. Results confirmed both propositions. Implications for the study of mental pain and suicide are discussed.

Pain perception in recovered bulimia nervosa patients.

OBJECTIVE: Decreased pain sensitivity is found in individuals who are ill with bulimia nervosa (BN). The purpose of this study is to determine whether altered pain perception persists after recovery from bulimia nervosa (RBN). METHODS: Eleven women who were recovered from BN for more than 1 year were compared with 15 healthy volunteer women. The participants received two pain evaluations--thermal pain stimulation (TPS), which evaluates threshold and tolerance to heat, and the submaximal effort tourniquet test (SETT), which assesses threshold and tolerance to ischemic pain induced by inflation of a blood pressure cuff. RESULTS: Compared with the controls, the RBN women showed elevated pain threshold as measured with the SETT and a tendency to elevated pain threshold on the TPS. DISCUSSION: Decreased pain sensitivity persists after recovery from BN and may reflect altered modulatory function in this illness.