From ideation to action : Analyses of predictors of suicidal ideation and behavior
Abstract in German
Suizidale Gedanken und suizidales Verhalten, das zu Suizidversuchen oder gar Suiziden führt, sind ein weltweit verbreitetes Phänomen, das bereits vielfach untersucht wurde. Doch wie können suizidale Gedanken frühzeitig erkannt werden, um den Übergang zum suizidalen Verhalten zu verhindern? Diese Frage zu beantworten, hat die vorliegenden Dissertation motiviert, in der die Erforschung von Risikofaktoren suizidaler Gedanken und suizidalen Verhaltens im Zentrum stand. In den vergangenen fünfzig Jahren wurden zwar viele verschiedene distale Risikofaktoren identifiziert, die Suizidversuche jedoch nicht wesentlich besser als Zufall vorhersagen können. Deshalb berücksichtigt die Forschung heute vermehrt proximale Risikofaktoren und integriert diese in sogenannte ideation-to-action Modelle, die zwischen der Entstehung von suizidalen Gedanken und dem tatsächlichen suizidalen Verhalten unterscheiden. Eines dieser Modelle ist das Integrative Motivational-Volitionale Modell Suizidalen Verhaltens (IMV Modell). Für die Entwicklung suizidaler Gedanken stellt das IMV Modell vor allem die beiden Konstrukte Defeat und Entrapment in den Vordergrund. Doch erst in jüngster Zeit konnte gezeigt werden, dass auch interozeptive Defizite sowohl bei suizidalen Gedanken als auch bei suizidalem Verhalten eine Rolle spielen.
Mit ihren drei Studien verfolgte die Dissertation drei, aufeinander aufbauende Ziele: Die erste Studie zielte darauf ab, im Rahmen des IMV Modells eine deutsche ökonomische Skala zur Erfassung der Konstrukte Defeat und Entrapment für die Suizidrisikoabschätzung zu validieren und die Faktorstruktur der Skala zu überprüfen. Konfirmatorische Faktorenanalysen zeigten, dass Defeat und Entrapment zwar miteinander assoziiert sind, aber als zwei separate Konstrukte betrachtet werden müssen. Mit Hilfe dieser Skala ließen sich Personen mit suizidalen Gedanken oder einem Suizidversuch von Personen unterscheiden, die keine suizidalen Gedanken hatten oder keinen Suizidversuch unternommen hatten.
Die zweite Studie zielte darauf ab, die Rolle von Defeat und Entrapment in der Vorhersage suizidaler Gedanken weiter zu analysieren und dabei den vom IMV Modell postulierten Pfad zur Entwicklung suizidaler Gedanken zu überprüfen. Mehrebenenanalysen zeigten, dass es im Rahmen des IMV Modells notwendig ist, zwischen internalem und externalem Entrapment zu differenzieren, da nur Defeat und internales Entrapment (Veränderungen in) Suizidgedanken vorhersagen konnten.
Die dritte Studie zielte zunächst darauf ab, Interozeption erstmalig im Rahmen eines innovativen Smartphone basierten ambulanten Assessments genauer zu untersuchen. Mehrebenenanalysen zeigten erstmalig, dass interozeptive Sensibilität, interozeptives Bewusstsein und interozeptive Genauigkeit intraindividuellen Schwankungen unterliegen und daher im Klinischen Setting wiederholt erhoben werden sollten. Diese essentiellen Schwankungen, die bereits ebenfalls für suizidale Gedanken und mehrere Risikofaktoren (u. a. defeat und entrapment) gezeigt werden konnten, können von zentraler, bisher jedoch weitgehend vernachlässigter Bedeutung in der Suizid-Risikoabschätzung sein und liefern wertvolle Informationen über die zeitliche Stabilität interozeptiver Facetten als mögliche Risikofaktoren suizidaler Gedanken und suizidalen Verhaltens. Interozeptive Defizite können als zusätzlicher Prädiktor in das IMV Modell integriert werden.
Die drei Studien bestätigen, dass die Messung von Defeat und Entrapment im Rahmen der Suizidrisikoabschätzung zu empfehlen ist. Gleichzeitig machen die Ergebnisse jedoch deutlich, dass einerseits die Differenzierung der Konstrukte verbessert werden muss, andererseits sollte Interozeption und ihre Schwankungen innerhalb der Suizidrisikoabschätzung berücksichtigt und in die postulierten Pfade des IMV Modells integriert werden. Beides wird voraussichtlich in Zukunft zu einer verbesserten Früherkennung suizidaler Gedanken und suizidalen Verhaltens beitragen .
Abstract in English
Suicidal ideation and behavior that lead to suicide attempts or even to suicide are worldwide phenomena that have been intensively studied. But how can suicidal ideation be recognized early, and what exactly characterizes the transition from suicidal ideation to actual suicidal behavior? Answering these questions motivates the present dissertation, which focuses on investigating risk factors of suicidal ideation and suicidal behavior. Although many different risk factors have been identified over the past 50 years, suicide attempts cannot be predicted any better than a random event. For this reason, research is increasingly taking into account proximal risk factors and integrating them into so-called ideation-to-action models. These models distinguish between the development of suicidal ideation and actual suicidal behavior. One of these models is the integrated motivational–volitional model of suicidal behavior (IMV model). For the development of suicidal ideation, the IMV model focuses on the two constructs defeat and entrapment. But recent research has shown that interoceptive deficits may also play a role in suicidal ideation and suicidal behavior.
With its three studies, this dissertation pursued three consecutive objectives. The first study aimed to validate an economic German scale for detecting the constructs defeat and entrapment for the assessment of suicide risk in the IMV model and to review the factor structure of the scale. Confirmatory factor analyses showed that defeat and entrapment are associated with one another but must be considered as two separate constructs. This scale could distinguish persons with suicidal ideation or one or more suicide attempts from persons who had no suicidal ideation or did not attempt suicide.
The second study aimed to further analyze the role of defeat and entrapment in predicting suicidal ideation and, in doing so, to examine the path postulated by the IMV model for the development of suicidal ideation. Multilevel analyses showed that it is imperative to differentiate between internal and external entrapment in the IMV model, which has not yet been done, even though only defeat and internal entrapment were predictive of (a change in) suicidal ideation.
The third study aimed to further examine interoceptive facets and their assessment in the framework of an innovative smartphone-based ambulatory assessment (ecological momentary assessment), which allows data collection in real time and in the private environments of participants. Multilevel analyses showed for the first time that interoceptive sensitivity, interoceptive awareness, and interoceptive accuracy are subject to intraindividual fluctuations and therefore have to be repeatedly collected in clinical settings. These essential fluctuations, which have also been shown for suicidal ideation and for several risk factors (e.g., defeat and entrapment), might be of central importance in assessing suicide risk but have largely been neglected, even though they deliver valuable information about the temporal stability of interoceptive facets as risk factors for suicidal ideation and behavior. Interoceptive deficits could be integrated into to the IMV model as an additional risk factor.
The three studies confirm how important it is for suicide prevention to assess the constructs defeat and entrapment in clinical practice. At the same time, the results make clear that the constructs need to be better differentiated and that interoceptive facets and their fluctuations need to be taken into account in the assessment of suicide risk using repeated assessments and should be integrated in the postulated pathways of the IMV model. This will contribute to even more success in the early detection of suicidal ideation and suicidal behavior in the future.
Suicidal ideation and behavior that lead to suicide attempts or even to suicide
are worldwide phenomena that have been intensively studied. But how can
suicidal ideation be recognized early, and what exactly characterizes the
transition from suicidal ideation to actual suicidal behavior? Answering these
questions motivates the present dissertation, which focuses on investigating
risk factors of suicidal ideation and suicidal behavior. Although many different
risk factors have been identified over the past 50 years, suicide attempts
cannot be predicted any better than a random event. For this reason, research
is increasingly taking into account proximal risk factors and integrating them
into so-called ideation-to-action models. These models distinguish between
the development of suicidal ideation and actual suicidal behavior. One of these
models is the integrated motivational–volitional model of suicidal behavior
(IMV model). For the development of suicidal ideation, the IMV model focuses
on the two constructs defeat and entrapment. But recent research has shown that interoceptive deficits may also play a role in suicidal ideation and suicidal
behavior. With its three studies, this dissertation pursued three consecutive objectives. The first study aimed to validate an economic German scale for detecting the constructs defeat and entrapment for the assessment of suicide risk in the IMV model and to review the factor structure of the scale. Confirmatory factor analyses showed that defeat and entrapment are associated with one another but must be considered as two separate constructs. This scale could distinguish persons with suicidal ideation or one or more suicide attempts from persons who had no suicidal ideation or did not attempt suicide.
The second study aimed to further analyze the role of defeat and entrapment in
predicting suicidal ideation and, in doing so, to examine the path postulated by
the IMV model for the development of suicidal ideation. Multilevel analyses
showed that it is imperative to differentiate between internal and external
entrapment in the IMV model, which has not yet been done, even though only
defeat and internal entrapment were predictive of (a change in) suicidal ideation.
The third study aimed to further examine interoceptive facets and their
assessment in the framework of an innovative smartphone-based ambulatory
assessment (ecological momentary assessment), which allows data collection in real time and in the private environments of participants. Multilevel analyses showed for the first time that interoceptive sensitivity, interoceptive awareness, and interoceptive accuracy are subject to intraindividual fluctuations and therefore have to be repeatedly collected in clinical settings. These essential fluctuations, which have also been shown for suicidal ideation and for several risk factors (e.g., defeat and entrapment), might be of central importance in assessing suicide risk but have largely been neglected, even though they deliver valuable information about the temporal stability of interoceptive facets as risk factors for suicidal ideation and behavior. Interoceptive deficits could be integrated into to the IMV model as an additional risk factor.
The three studies confirm how important it is for suicide prevention to assess
the constructs defeat and entrapment in clinical practice. At the same time, the
results make clear that the constructs need to be better differentiated and
that interoceptive facets and their fluctuations need to be taken into account
in the assessment of suicide risk using repeated assessments and should be integrated in the postulated pathways of the IMV model. This will contribute
to even more success in the early detection of suicidal ideation and suicidal
behavior in the future.
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