Interpersonal beliefs related to suicide and facial emotion processing in psychotic disorders
Introduction
About 5% of people with psychotic disorders die by suicide (Palmer et al., 2005) and a third attempt suicide in their lifetimes (Pompili et al., 2007), with a standardized mortality rate 3.9 times that in the general population (Olfson et al., 2015). Despite the exceptionally high risk for lifetime suicidal ideation and behavior in psychotic disorders (schizophrenia, schizoaffective disorder, bipolar disorder), the illness specific mechanisms underlying risk for suicide are not well understood (Kasckow et al., 2011).
Although several of the risk factors associated with histories of suicide attempts in people with psychotic disorders parallel that in the general population (e.g., history of prior attempts, the presence of depressive symptoms; Pompili et al., 2007), some risk factors differ. In the general population, educational attainment and cognitive ability are negatively associated with histories of suicidal ideation and behavior (Kosidou et al., 2014), whereas a number of studies indicate history of attempts are associated with higher cognitive ability in schizophrenia (Kim et al., 2003; Nangle et al., 2006; Villa et al., 2018). A recent meta-analysis found a stronger link between the presence of ideation and suicidal behavior in psychotic disorders than in mood disorders (Chapman et al., 2015), as well as more lethal attempts (Kelleher et al., 2013). Within the illness, the symptom clusters of psychotic disorders appear to be differentially correlated with suicide - positive symptoms (e.g., paranoia and hallucinations) can be associated with increased suicide risk (Castelein et al., 2015), whereas negative symptoms are associated with decreased risk (Hawton et al., 2005). Therefore, due to the elevated risk associated with psychotic disorders and the evidence for somewhat unique determinants of suicide both within the illness and in comparison with other psychiatric disorders, it is important to evaluate potential mechanisms underlying suicidal ideation and behavior in psychotic disorders.
One area that has received comparatively little attention as associated with suicide risk in psychotic disorders is social cognition. Nonetheless, many theoretical accounts of the psychological mechanisms underlying suicide in psychosis (Johnson et al., 2008), and in the general population, feature the presence of maladaptive interpersonal beliefs as central to risk (e.g., the Interpersonal-Psychological Theory of Suicidal Behavior; Joiner et al., 2009; Van Orden et al., 2010). These include perceptions of rejection and ostracization from others, social defeat, experiencing oneself as a burden, and low appraisals of belonging and availability of support/rescue from distress (Johnson et al., 2008; Van Orden et al., 2010). The Interpersonal Needs Questionnaire (INQ) was developed to assess two of these constructs (thwarted belongingness, perceptions of being a burden to others), but to our knowledge, this measure has had limited usage in psychotic disorders (Silva et al., 2015; Taylor et al., 2016).
At a more basic level, one aspect of social cognition commonly associated with psychiatric disorders is the aberrant processing of emotions in others (Green et al., 2015; Kohler et al., 2010; Lee et al., 2013), in particular biases in identification of threats such as anger (Pinkham et al., 2011; Ruocco et al., 2014). In the few studies that have investigated social cognitive ability and suicide risk in psychosis, patients displayed deficits on social cognitive tasks relative to comparative groups, with impairment specific to patients with past suicide attempts (Duño et al., 2009; Harenski et al., 2017; Lakimova et al., 2016). In particular, Lakimova et al. (2016) found a negative association between the number of suicide attempts and accurate recognition of anger and disgust in schizophrenia. In a study of facial affect recognition in a sample of persons with schizophrenia, with and without paranoia, Pinkham et al. (2011) found that paranoia was associated with misperception of threat to neutral stimuli. Using ecological momentary assessment, in which a sample of patients with schizophrenia responded to questions about social activities and appraised these activities, we found that patients with recent suicidal ideation were more likely to perceive social interactions as “not worth the effort” (Depp et al., 2016). Participants with recent suicidal ideation were also twice as likely to predict being alone in the near future as compared to patients without recent ideation, despite spending approximately the same amount of time in social interactions and with others, suggesting no real differences in social activity. As such, these preliminary data indicate that aberrant social cognition and appraisals may have bearing on suicidal thoughts and behavior in schizophrenia.
To address these gaps in the literature, we evaluated the associations between maladaptive interpersonal beliefs related to suicidality, as measured by the Interpersonal Needs Questionnaire (INQ), and facial emotion processing, as measured by the Penn Emotion Recognition Test (ER-40). We also evaluated associations between INQ and ER-40 scores with history of past suicide attempts and current suicidal ideation severity. We hypothesized that INQ would be associated with ER-40 scores, and with greater bias in perceiving anger in neutral faces as a measure of social threat, as in a prior study associating this bias with current paranoia (Pinkham et al., 2011) and in the deleterious effects of loneliness (Cacioppo et al., 2015). Additionally, we hypothesized that INQ and ER-40 total scores and bias toward angry facial emotions would be associated with severity of current suicide ideation and a higher rate of past suicidal behavior. We also examined the specificity of these effects after adjustment from other clinical variables, in particular whether these associations persisted after adjusting for general cognitive ability, given that greater cognitive ability is associated with suicidal ideation and behavior in schizophrenia (Kim et al., 2003; Nangle et al., 2006; Villa et al., 2018) and with global estimates of current psychopathology.
Section snippets
Participants
Data from this study included baseline data from an ongoing randomized controlled trial evaluating the effectiveness of different mobile-health augmented interventions in serious mental illnesses. Baseline data was recorded prior to randomization. For the current study, we included data from 101 adults aged 18 and older with a diagnosis of schizophrenia or schizoaffective disorder (N = 75) and bipolar I disorder (N = 26). The total sample recruited was 255 patients, and supplemental funding was
Sample characteristics (Table 1)
The sample was, on average, slightly more likely to be female (54.5%), middle-aged (M = 49.9 years, SD = 11.3), and ethnically diverse, with an average level of education completed at a high school level. A majority of patients had experienced passive suicidal ideation (67.3%); histories of active ideation (30.7%) or suicide attempts (39.6%). The average number of lifetime attempts among persons with attempt history was 2 (SD = 6.4). In comparing diagnoses, and as expected, a diagnosis of
Discussion
In this pilot study, we examined the relationship among maladaptive interpersonal beliefs and facial emotion processing with suicidality in psychosis. Adding support to the Interpersonal-Psychology Theory of Suicidal Behavior positing burdensomeness and thwarted belongingness as constructs underlying suicidality (e.g., Van Orden et al., 2010), we found that INQ scores were associated with history of suicide attempts and current ideation. Novel in this study was the examination of INQ ratings
Conflicts of interest
Dr. Harvey has served as a consultant to Allergan, Boehringer-Ingelheim, Lundbeck, Otsuka Digital Health, Sanofi, Sunovion, and Takeda Pharma. Granholm reported consulting fees from Otsuka America Pharmaceutical, Inc. These relationships are not related to the topic of this paper. None of the other authors have any conflicts of interests to report.
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