Motivation and emotion/Book/2018/Suicidality across the lifespan

Overview
Trigger warning:

This chapter centers the information on suicide, which may leave readers in discomfort. If you, or anyone you know have suicidal thoughts, please take a break from reading this chapter, or call for help:

Lifeline Australia: 13 11 14

Suicide call back service: 1300 659 467Suicide is one of the leading causes of death worldwide, with the World Health Organisation (2018) stating that close to 800,000 people die by suicide each year globally. There is an abundance of research relating to suicide and suicidal behaviour, with some suggesting that suicidal thoughts are the primary predictors of suicidal behaviours (Nock et al., 2008). This chapter will look specifically at suicidality, and suicidal motivations across the lifespan.

What will this chapter cover?


 * Relevant theories of suicidality motivation
 * Suicidality motivations across the lifespan:
 * Infancy and childhood
 * Adolescence
 * Adulthood
 * Maturity
 * Overcoming suicidalty
 * Conclusion

See also: Signs and symptoms linked to suicidality

Theories of suicidality motivation
There are several theories relevant to the topic, with many building on past models to create a more comprehensive view of suicidality. Self-discrepancy theory, escape theory, interpersonal-psychological theory, the integrated motivational-volitional model, and self-determination theory are discussed.

Self-discrepancy theory and suicidal ideation: The role of self-awareness
See also: Self-discrepancy theory

Self-discrepancy theory proposes that people are motivated to reach a point when their self-concept matches their own self-guides. It states that, when people see a difference between the actual self and the ideal and ought selves, they experience self-discrepancy, and when they become conscious of this discrepancy, they experience discomfort and many negative psychological affects (Higgins, 1987). Further, there is research that suggests that high self-awareness (and the ability to evaluate the distance to our goals that comes with it) can be associated with depression, feelings of guilt, and even lead to an increase in suicide-related cognition when people experience a great divergence between the self-concept and self-guides and they feel the need to escape this self-awareness (Selimbegović & Chatard, 2013; see below: Escape theory of suicide).

Escape theory of suicide
The main premise behind this theory is that people who attempt suicide are not doing so because they desire death itself, rather, they are motivated to escape the self. Baumeister (1990) found that individuals who have thoughts of suicide, or have suicidal behaviours tend to have high standards and self awareness, hold negative views of themselves, experienced recent setbacks. There is also evidence that the greater the discrepancy between the standard and the person's actual experience, the greater the inadequacy they feel (see: Self-discrepancy theory and suicidal ideation: The role of self-awareness) and that "attempting to kill onself may help the person to escape awareness of problematic life circumstances and inadequacies of the self. The wish to die may arise from just such desires for escape" (p. 108). He highlights six main steps involved suicidality:


 * 1) Falling short of standards
 * 2) Attributions to the self
 * 3) High self-awareness
 * 4) Negative affect
 * 5) Cognitive deconstruction
 * 6) Consequences of deconstruction

There is also supporting evidence that it is not necessarily negative events which occur that cause suicidal ideation, but rather it is the feeling of hopelessness in relation to those events, depression, and reasons for living which ultimately determine whether the individual experiences suicidal thoughts (Dean & Range, 1999).

Interpersonal-psychological theory of suicide
See also: Interpersonal theory of suicide

The need to belong is most definitely an innate human need, and people are thus motivated to be accepted by others (Baumeister & Leary, 1995). The interpersonal theory of suicide postulates that suicidal desire is an accumulation of thwarted belongingness, which is the feeling of being isolated from others, and perceived burdensomeness, which is when an individual feels that others would be better off if they were no longer in the picture. There is research supporting the theory that thwarted belongingness and perceived burdensomeness are distinct constructs that can be measured, and that measurements of these constructs is a viable tool to assess suicidal desire in people (Van Orden, Cukrowicz, Witte, & Joiner, 2012). So, if people feel like they do not belong, or if they have feelings that they are a burden on others, they may feel suicidal desire due to their psychological need of 'social belongingness' not being fulfilled.

Silva, Ribeiro and Joiner (2015) found that disorders such as bipolor disorder, borderline personality disorder, schizophrenia, and other psychotic disorders were associated with the perceived burdensomeness and thwarted belongingness, which may in turn increase suicidality in these individuals.

The integrated motivational–volitional (IMV) model of suicidal behaviour
The IMV model states that one's intention to engage in suicidal behaviour is determined by feelings of entrapment, which in turn leads to the person feeling as though suicidal behaviour is the solution to life's problems. Entrapment has been found to be a distinct factor in suicidal ideation and behaviours (O’Connor & Kirtley, 2018; Forkmann & Teismann, 2017).

The theory outlines eight Volitional Factors:
 * 1) Access to means
 * 2) Planning
 * 3) Exposure to suicide or suicidal behaviour
 * 4) Impulsivity
 * 5) Physical pain sensitivity/endurance
 * 6) Fearlessness about death
 * 7) Mental imagery
 * 8) Past suicidal behaviour

When factors combine (not necessarily all at once), this leads individuals to go from the planning or ideation stage, to the suicidal behaviour stage, which then turns into somewhat of a cycle.

Self-determination theory and basic psychological needs: The role of autonomy, competency, and relatedness
See also: Self-determination theory

According to this theory, people are intrinsically motivated to grow and learn from challenging situations, thereby actualising their potential. There are, however, challenges faced in life when those situations may prevent one from developing into their best self. Thus, there are three basic psychological needs that need to be met in order for the person to thrive. If any of these basic psychological needs are thwarted, people experience physical and mental ill-being, which can lead to suicidal ideation and potential suicidal behaviour (Britton, Van Orden, Hirsch & Williams, 2014).

Autonomy
Behaviour should be self-directed, and in line with the person's beliefs and values. If a person is in a situation where they are being very much extrinsically motivated, or if situations restrict their own control over their lives, they experience incongruence regarding their intrinsic need for autonomy.

Competency
People should have the feeling that they are able to accomplish goals and excel in life. People who are intrinsically motivated to do a task will seek out opportunities for them to learn and eventually experience mastery.

Relatedness
People are inherently social beings and in order for them to remain motivated and well, they require meaningful interactions, connections, and caring for, and from, others.

Suicidality motivations across the lifespan


For a recent world suicide death rate by age see: Our World in Data: Suicide Death Rate by Age

Karch, Logan, McDaniel, Parks and Patel (2012) note the following commonalities as reasons behind suicide in a U.S. population: mental illness or mental health problems (specifically depressed mood), intimate partner problems, crisis, ill physical health, and job or financial problems. It is important to also note that there is a specific predictor of suicidality that spans across the lifespan: with alarmingly high rates of suicide in transgender people and other members of the LGBT+ community, research points to the fact that these minorities are more likely to experience thwarted belongingness and perceived burdensomeness (see: Interpersonal-psychological theory of suicide), which in turn increases risk of suicide (Testa, et al., 2017; Woodward, Wingate, Gray & Pantalone, 2014). Children, adolescents, and adults are all at greater risk of suicide if they have had previous non-fatal self-harm attempt/s (Olfson, et al., 2018).

The following age-groups (grouped similiarly to Erikson's stages of psychosocial development) are discussed in terms of suicidality motivation:

Infancy and childhood
Under 2 years- 12 years

As seen in Figure 1, and also at Our World in Data: Suicide Death Rate by Age, suicide rates in children under the age of 14 are very small in comparison to other age groups, and children under 5 years are not generally considered to have suicidal tendencies. There are, however, cases of suicidal thoughts or even suicidal attempt have been seen in children, with most of the research available being on children as young as 10-12 years.

Depression
While the study by de Araújo Veras, Ximenes, de Vasconcelos, and Sougey (2016) is mostly on children who could be considered adolescents, results are still relevant to the childhood age group as well (see below: Depression in adolescents and suicidality motivations).

Maltreatment and the family environment
Rhodes et al. (2013) looked at child maltreatment and presentations to the emergency department in a sample of 12-17 year-old Canadian children and youths. They identifed that children who are maltreated are two times more likely to present to the emergency department for suicide-related behaviours. There are also associations between lifetime suicide ideation and an adversive or unsupportive family environment during childhood in adults (Susukida, Wilcox, & Mendelson, 2016), however, causation cannot be confirmed.

Relationships
In their study, Sheftall, et al. (2016) found that, among other facts of suicide in this age group (such as most of those who committed suicide being black, male, dying at home by hanging/strangulation/suffocation), relationship problems were motivators for suicide in this age group. Children who died by suicide were more likely to have experienced familial relationship problems, and early adolescents who died by suicide likely experienced boyfriend/girlfriend problems.

Bullying
Research looking at 9-14 year old Canadian students shows that children who are bullied, whether it be through verbal or electronic means, are more likely to have suicidal ideation (Feng, Waldner, Cushon, Davy & Neudorf, 2016). This is in line with a meta-analysis by Gini and Espelage (2014), who found that bullying is associated with higher rates of suicidality in children and adolescents. They also distinguish that cyberbullying seems to be a greater catalyst for suicidal ideation and behaviour. However, not everyone who is bullied has suicidal ideation. Researchers put forth "depression, history of sexual abuse, or family violence" (p. 546) as possible mediators between bullying and suicidality, and suggest that these should be researched further when looking at bullying and suicidality in this age group.

Adolescence
12 years-19 years

The motivations for suicide, and suicide-related behaviours in adolescence seem to be similar to those outlined in Infancy and childhood. However, the World Health Organisation (2018) states that suicide "is the second leading cause of death among 15-29 year olds globally" (para. 1). With research showing that adolescents with previous self-injurious thoughts and behaviours are two times as likely to die from suicide attempt (Castellví, et al., 2017), it is not surprising then, that there are more studies looking at this age group and adulthood than others. The motivations for suicidality in this age group are discussed:

Depression
In their study looking at 10-17 year-olds in Brazil, de Araújo Veras et al. (2016) found that depressive symptoms are significantly associated with suicidality. Similar findings were also demonstrated in the study by du Roscoät, Legleye, Guignard, Husky, and Beck (2016).

Maltreatment and the family environment
There are, of course, many ill-effects to maltreatment, and the long-term effects of childhood abuse and maltreatment are well documented in relation relation between negative events in childhood and lifetime suicidality (see the Rhodes et al. (2013) and Susukida, et al. (2016) studies above: Maltreatment in childhood, which also included children up to the age of 17 years, and analysed up to adulthood in adults respectively). And relationships with parents are shown to be a predictor of suicidal attempts (du Roscoät et al., 2016). However, the work of Lipschitz, Yen, Weinstock and Spirito (2012) indicates a discrepancy between the perceived family functioning when looking at results from the children in question, and results from their caregivers. The findings came from the results of a variety of self-report questionnaires presented to 103 adolescents hospitalised for suicidal ideation and/or behaviour, and their caregivers. The adolescents ratings of family functioning were significantly worse. This research has significant implications for the early detection, and treatment of suicidality.

Bullying
In their study, Hinduja and Patchin (2010) looked at 1963 US middle-schoolers and measured for suicidal ideation, and victims and perpetrators of both traditional bullying and cyberbullying. Interestingly, they found that both victims and bullies were both almost twice as likely to have attempted suicide, however, unsurprisingly, victims of bullying were more likely to have suicidal thoughts and behaviours than bullies and others who had not experienced this peer aggression (as either a bully or victim). Similar results were found in an Australian sample of 14-15 year-olds (Ford, King, Priest & Kavanagh, 2017). Researchers found that bully-victims had a higher likelihood of self-harming, suicidal thoughts, plans of suicide, and attempted suicide, in either verbal or physical bullying. Researchers noted that there were even worse outcomes for children who experienced both verbal and physical bullying. Luk, Gilman, Haynie and Simons-Morton (2018) found that sexual minority adolescents were more likely to be victims of cyberbullying, and there is research outlining the ill-effects (self-harm, suicidality, suicidal thoughts and attempt) of bullying in adolescents with obesity (Pont, Puhl, Cook, & Slusser, 2017).

Looking through the lense of interpersonal-psychological theory, Arango, Opperman, Gipson, and King (2016) measured their sample of adolescents on bullying (including electronic or cyberbullying), social connectedness, and suicidal thoughts and behaviours. Results found that bullying and lower social connectedness scores were associated with increased suicidal ideation and risk for suicide attempts. Could bullying lead to lower social connectedness, and in turn thwart percieved belongingness to the group? (see above for an overview of the implications of thwarted belongingness in: interpersonal-psychological theory of suicide).

Use of the internet and social/online media
See below: Use of the internet and social/online media in adults. When looking specifically at adolescents in their analysis of the literature, Shain (2016) reports that pathological internet use is related to suicidality. They also comment that higher usage of internet and video games signinficantly predicts higher levels of depression and suicide attempt and ideation. There is also research that pro-suicide websites, and suicide-related searches, promote and facilitate suicidal behaviour, and in some cases, even lead to the development of "suicide pacts" (Durkee, Hadlaczky, Westerlund & Carli, 2011). It is also important to consider the type of content that adolescents have access to. Durkee et al. (2011) highlight the fact that adolescents may have access to the internet, and may even search ways of suiciding.

Could all of this be due to the "glamorisation" of suicide in popular television shows and in the media? Murphy (2017) writes a news article detailing the unfortunate deaths by suicide of two schoolgirls who parents claim was as a result of watching a popular TV show on Netflix called 13 Reasons Why. Others report similar stories accross the globe (Charlton, 2017; Godden, 2017).

Insomnia and sleep disturbances?
Some research has suggested a link between sleep problems, nightmares, and insomina and suicide in adolescents and adults (Goldstein, Bridge & Brent, 2008; Pigeon, Titus & Bishop, 2016). However, research by Zullo et al. (2017) seems to suggest that, while improved sleep may reduce suicidality, the interpersonal-psychological theory of suicide seems to answer the question as to what motivates people to suicide best, with percieved burdensomeness and depressive symptoms explaining this relationship, rather than insomnia being a causal factor.

Adulthood
19 years- 65 years

In the U.S., the rate of suicide amongst middle-aged people increased significantly by 28.4% from 1999 to 2010 (Chakravarthy, Frumin & Lotfipour, 2014). What are the motivations behind this? Research shows that there are many possible factors that contribute to overall suicidality, from financial hardship and job-loss, psychological need-satisfaction, the use of the internet, and failure to meet standards.

Financial threat, economic hardship, and job loss
There has been research that suggests that job loss or even the threat to Job Security (i.e. job insecurity) can lead to worse mental and physical health outcomes, and more psychological distress (Chirumbolo & Hellgren, 2003; Vander Elst, Näswall, Bernhard-Oettel, De Witte & Sverke, 2016; Paul & Moser, 2009). In line with this research, Fiksenbaum, Marjanovic, Greenglass and Garcia-Santos (2017) looked at whether economic hardship or financial threat was associated with psychological distress (suicide ideation and cognitive confusion) in two populations (Canadian and Portugese). Using convenience samples from undergraduate psychology students, results found a positive correlation between past ecoonomic hardship, current economic hardship, financial threat, and psychological distress. While the study looked at a limited sample, their findings are supported by other research, which found similar results in regards to the 2008 global economic crisis, in which researchers found an increase in suicide rates across 52 countries globally (Chang, Stuckler, Yip & Gunnell, 2013). Similarly, Chang, Gunnell, Sterne, Luc & Cheng (2009) found that, during the economic crisis of 1997-1998, countries in Asia that were more affected by this crisis showed a greater increase of suicide, with an average increase in suicide rate of 10,400 from 1997 to 1998 in three of the countries analysed. They also noted that working-aged men were more affected than women or retirees.

Psychological need-satisfaction
When looking at Self-determination theory (also outlined above: Self-determination theory and basic psychological needs), we can see that there are certain psychological needs (competence, relatedness, autonomy) that have to be met in order for a person to thrive. Looking through the lense{sp}} of this theory, Britton et al. (2014) aimed to acertain whether satisfaction of these needs reduces suicidal ideation and risks of suicidal behaviour in young adults. Participants were 440 undergraduate psychology students with a mean age of 21.01. Measures were taken of basic psychological needs, suicidal ideation and risk for suicidal behaviour, as well as depressive symptoms. Results found that when participants had an overall need satisfaction, they showed lower likelihood of risk of suicidal behaviour and suicidal ideation. This research is similar to the findings by Rowe, Walker, Britton and Hirsch (2013). Their study of 439 undergraduate students found that those who experienced negative life events (measured using the Life Events Scale (also known as the Holmes and Rahe Stress Scale)) were more likely to engage in suicidal behaviour. They also found that when people have a greater fulfillment of the needs of competence, relatedness, and autonomy, they show lower suicidal behaviour, even suggesting that the fulfillment of these basic needs could buffer against the ill-effects (suicidal ideation or behaviour) of negative life events.

Use of the internet and social/online media
In their study looking at 305 undergraduates, Moberg and Anestis (2015) aimed to see if online social interactions could be a potential risk factor in suicidal desire by looking at the constructs outlined in the interpersonal theory of suicide (also outlined above: Interpersonal-psychological theory of suicide). Researchers took measures of internet use, problematic internet use, self-reported depression, anxiety, and stress levels, and measures of thwarted belongingness and percieved{sp}} burdensomeness. Findings supported their hypothesis that internet use, specifically negative interactions on social media sites, is correlated with greater levels of thwarted belongingness, which, as we know, can affect behaviour, particularly suicidal ideation. They also found that depression is associated with problematic internet use, and that positive online interations{sp}} correlated with lower depression levels. They It is important to note that, while participants were aged 18- 45, the mean age was 20.61, with a standard deviation 3.82. This means that these findings are also relevant to the adolescence age group.

See also: Use of the internet and social/online media in adolescents

Failure to meet standards
In their studies looking at university students, Chatard and Selimbegović (2011) aimed to see if suicide-related thoughts were more easily accessible in the event of standard-failure. They found that negative self-awareness after failure leads to the person wanting to escape from that self-awareness, which in turn, leads to more suicidal thoughts, especially in those participants low in self-consciousness. They also found that there is a stronger likelihood of people having suicidal thoughts when they are faced with the idea of unemployment or poverty when they live in a country where the standard of living is high, which leads to a greater discrepancy and worse psychological implications, which is consistent with other research (see: Escape theory of suicide and Self-discrepancy theory and suicidal ideation: The role of self-awareness).

Physical disablement
When looking at motivations for suicide in persons with health conditions and physical disabilities, Khazem, Jahn, Cukrowicz and Anestis (2017) linked physical disablement with feelings of percieved{sp}} burdensomeness (see: interpersonal-psychological theory of suicide), which in turn lead to depressive symptoms and suicidal ideation.

Maturity
65 years- death

See: Suicidality in the elderly

Meeting needs and changing perspective
As discussed (Psychological need-satisfaction), when people experience their psychological needs being met, these aspects can provide a buffer to the ill-effects of negative life events. Indeed, their meta-analysis, Ng, Ntoumanis, Thøgersen-Ntoumani, Deci, Ryan, Duda and Williams (2012) reiterate the importance of self-determination theory, and how the use of this theory could lead to possible interventions within health care contexts. They believe that if health care professionals, parents, educators, employers, etc. promote and support a person's autonomy, competency, and relatedness, interventions can "improve the length and quality of individuals' lives" (p. 337). There is also strong evidence for the use of a combination of Cognitive Behavioral Therapy (or CBT) in conjunction with Motivational Interviewing (MI) as being most effective in treatment or prevention of suicidality (Britton, Patrick, Wenzel & Williams, 2011). Researchers believe that by using MI as a way to assess need fulfillment, optimal CBT techniques can be employed when treating patients.

Support for the use of CBT in overcoming suicidalty can also be found in Higgins' (1987) discussion of self-discrepancy theory. He mentions the possibility of modifying a person's interpretations of performance, and change self-guides, to be more in line with their actual self-concept using cognitive behavioural therapies.

Social support
In a longitudinal study looking at 1085 participants over four years (with participants' ages starting from age 17-19 at the beginning of the study), Wilcox et al. (2010) found that 12% of their sample reported suicidal ideation over the four years. Although their sample of participants presenting with suicidal ideation was quite small, they identified several factors that could influence suicidal ideation: low social support, high depressive symptoms, exposure to domestic violence during childhood and adulthood, and, to an extent, maternal depression. They do, however, make sure to distinguish that those who had persistent suicidal ideation were no more likely to be at risk for attempting suicide than those who only reported suicidal ideation once. This study has implications for the prevention of suicide, highlighting the importance of social support, and suggesting that university campuses should promote social support networks to new and existing students.

Early detection
As discussed, childhood and youth events greatly affect lifetime suicidality. Percieved support from caregivers was a strong indicator for suicidality across the lifetime (Susukida et al., 2016), and the Rhodes et al. (2013) study showed that maltreated children are more likely to end up in hospital due to suicide-related behaviours. Other research also found that young adults were more likely to have maladaptive personality traits and suicidal behaviour if they were diagnosed with childhood anxiety or depression at a young age (Rudd, Joiner & Rumzek, 2004).

When taking into consideration the life-long consequences of childhood events, it comes as no surprise that the best way of overcoming suicidality (as an individual or as a community) is early detection and interventions. The Committee on Adolescence (2000) found that paediatricians are an invaluable source for the prevention of suicide, that, during check-ups on adolescents, they should ask questions relating to suicidality and risk, and they should also work in conjunction with families to support the person in question.

In terms of a school-setting, Scott, Wilcox, Huo, Turner, Fisher and Shaffer (2010) reiterate the importance of screening for suicide risk, putting forward a modified Columbia Suicide Screen as an effective (in both cost and accuracy) way for schools to screen for suicidality and other clinical mental health disorders. Indeed, the use of school-based mental health services could greatly reduce instances of suicide risk (Paschall & Bersamin, 2018).

Conclusion
We can see that suicidality is a complex and devastating phenomenon that affects humans across all ages. There are several noteworthy theories that attempt to ascertain how and why suicide occurs, and what internal mechanisms might be involved in suicide-type behaviours, suicidal ideation, etc. When taking into consideration these theories, we can see that there is a large amount of literature that supports the theories across all age-groups. We can also see that there is a large overlap in suicidality motivations across age-groups as well, with many motivations and causes stretching from childhood to adulthood and maturity.

In terms of overcoming suicidality, the best therapy seems to be CBT, however, there is an overwhelming amount of research that suggests that early detections and interventions are optimal for prevention of suicidality throughout the lifespan.