The interpersonal theory of suicide.

Multiple past attempts are an especially strong predictor of lethal suicidal behavior in both adolescents and adults.

“The presence of multiple past attempts is an especially strong predictor of lethal suicidal behavior in both adolescents (Kotila & Lonnqvist, 1987) and adults (Christiansen & Jensen, 2007; Haw, Bergen, Casey, & Hawton, 2007; Suominen, Isometsa, Haukka, & Lonnqvist, 2004; Zonda, 2006)”

• cites Kotila & Lonnqvist, 1987 sourceNot checked — no full text of the source
• cites Christiansen & Jensen, 2007 sourceNot checked — no full text of the source
• cites Haw, Bergen, Casey, & Hawton, 2007 sourcePartly supported

  The Results report that suicide or probable suicide was more frequent as the number of self-harm repetitions increased in the cohort. But the paper says this pattern for frequent repetition was found in females, not males; it also measures repetitions during follow-up rather than establishing multiple past attempts as an especially strong predictor. Haw et al. is cited for the adult portion of the sentence, not the adolescent portion. (LLM, conf=0.88)

  Experimental — accuracy not yet measured

Disorders with anxiety/agitation or impulse-control deficits are predictive of the transition from suicidal ideation to non-lethal suicide attempts.

“Disorders with anxiety/agitation as characteristic symptoms (i.e., generalized anxiety disorder, social phobia, PTSD, bipolar disorder) or impulse-control deficits as characteristic symptoms (i.e., conduct disorder, intermittent explosive disorder, substance use disorders) are predictive of the transition from suicidal ideation to non-lethal suicide attempts (Nock, et al., 2009).”

• cites Nock, et al., 2009 sourcePartly supported

  The Discussion says that disorders characterized by anxiety and poor impulse control were the strongest predictors of which people with suicidal ideation made plans and attempts. But the Results (Table 6) do not support treating every listed disorder as predictive of attempts among ideators: social phobia was not significantly associated with either planned or unplanned attempts in developed countries, and intermittent explosive disorder was not significantly associated with unplanned attempts. (LLM, conf=0.86)

  Experimental — accuracy not yet measured

Social isolation is arguably the strongest and most reliable predictor of suicidal ideation, attempts, and lethal suicidal behavior among samples varying in age, nationality, and clinical severity.

“Social isolation is arguably the strongest and most reliable predictor of suicidal ideation, attempts, and lethal suicidal behavior among samples varying in age, nationality, and clinical severity (Conwell, 1997; Dervic, Brent, & Oquendo, 2008; Joiner & Van Orden, 2008; Trout, 1980).”

• cites Conwell, 1997 sourcePartly supported

  The Social Milieu (page not provided) calls social isolation a likely risk factor for suicide in late life and reports an association between living alone and elderly suicide. It does not establish isolation as the strongest and most reliable predictor of ideation, attempts, and lethal behavior across ages, nationalities, and clinical severities; it also notes conflicting findings and limits to risk prediction. (LLM, conf=0.88)

  Experimental — accuracy not yet measured
• cites Dervic, Brent, & Oquendo, 2008 sourceNot checked — no full text of the source
• cites Joiner & Van Orden, 2008 sourceNot checked — no full text of the source

A prior history of suicidal behavior is one of the most reliable and potent predictors of future suicidal ideation, attempts, and death by suicide across the lifespan.

“one of the most reliable and potent predictors of future suicidal ideation, attempts, and death by suicide across the lifespan is having a prior history of this type of behavior”

• cites Table 1Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

The vast majority of individuals diagnosed with these mental disorders do not die by suicide.

“However, the studies listed in Table 1 also indicate that the vast majority of individuals diagnosed with the above disorders do not die by suicide.”

• cites Table 1Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

The literature indicates the most consistent and robust support for mental disorder, past suicide attempts, social isolation, family conflict, unemployment, and physical illness as risk factors for suicide.

“The literature indicates the most consistent and robust support for the following as risk factors for suicide: mental disorder, past suicide attempts, social isolation, family conflict, unemployment, and physical illness.”

• cites Table 1Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

More than one-third of people who die by suicide had a medical illness at the time of their death.

“A review by Whitlock (1986) demonstrated that more than one-third of people who die by suicide had a medical illness at the time of their death”

• cites Whitlock (1986)Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

The capacity to act suicidally is separate from the desire to act suicidally.

“the capability to engage in suicidal behavior is separate from the desire to engage in suicidal behavior”

A previous attempt with high medical lethality is a predictor of lethal suicidal behavior.

“as is a previous attempt with high medical lethality (Gibb, Beautrais, & Fergusson, 2005)”

• cites Gibb, Beautrais, & Fergusson, 2005Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Individuals with suicidal behaviors are often excluded from clinical trials due to safety concerns.

“Second, individuals with suicidal behaviors are often excluded from clinical trials due to safety concerns on the part of researchers (Rudd, Joiner, & Rajab, 2001).”

• cites Rudd, Joiner, & Rajab, 2001Not checked — no full text of the source

The capacity for suicidal behavior develops through habituation and opponent processes after repeated exposure to physically painful and/or fear-inducing experiences.

“the capability for suicidal behavior emerges, via habituation and opponent processes, in response to repeated exposure to physically painful and/or fear-inducing experiences”

The elevation in risk for lethal suicidal behavior conferred by a history of a previous attempt persists over the lifetime.

“A 37-year longitudinal study indicated that the elevation in risk for lethal suicidal behavior conferred by a history of a previous attempt persists over the lifetime (Suominen, Isometsa, Suokas, Haukka, Achte, & Lonnqvist, 2004).”

• cites Suominen, Isometsa, Suokas, Haukka, Achte, & Lonnqvist, 2004Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

The most dangerous suicidal desire results from the co-occurrence of thwarted belongingness and perceived burdensomeness, together with hopelessness about these states.

“We propose that the most dangerous form of suicidal desire is caused by the simultaneous presence of two interpersonal constructs—thwarted belongingness and perceived burdensomeness (and hopelessness about these states)”

The majority of medical illnesses do not appear to increase risk for suicide, including rheumatoid arthritis, diabetes, and hypertension.

“the majority of medical illnesses do not appear to actually increase risk for suicide, including rheumatoid arthritis, diabetes, and hypertension (Harris & Barraclough, 1997; Stenager & Stenager, 1992)”

• cites Harris & Barraclough, 1997 sourceNot checked — no full text of the source
• cites Stenager & Stenager, 1992 sourceNot checked — no full text of the source

Very large samples are needed to study suicide attempts and deaths because their base rates are low in the general population.

“First, very large samples are needed because the base rates of suicide attempts and deaths are low in the general population (Moscicki, 2001).”

• cites Moscicki, 2001 sourceNot checked — no full text of the source

Indices of family conflict are robust risk factors for lethal suicidal behavior across the lifespan.

“Indices of family conflict are robust risk factors for lethal suicidal behavior across the lifespan, with studies listed in Table 1 documenting associations between suicide and familial discord, domestic violence, familial stress, and perceptions that one is a burden on family.”

• cites Table 1Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

HIV/AIDS confers approximately a seven-fold risk for suicide compared to the general population.

“One disease with a particularly high risk for suicide is HIV/AIDS, which has been shown to confer approximately a seven-fold risk for suicide as compared to the general population (Conwell, 1994; Harris & Barraclough, 1997).”

• cites Conwell, 1994Not checked — no full text of the source
• cites Harris & Barraclough, 1997 sourceNot checked — no full text of the source

Another explanation for the relatively low number of empirical advances in understanding suicide may be the absence of a theory that comprehensively explains known facts and reliably identifies future risk.

“Thus, another explanation for the relatively low number of empirical advances in understanding the causes and correlates of suicide, as well as methods for suicide prevention, may therefore be the absence of a theory that can comprehensively explain known facts about suicide, as well as reliably and precisely identify risk for future occurrences of suicidal behavior.”

• cites Prinstein, 2008 sourceNot checked — no full text of the source

That study found no elevation in suicidal ideation among participants with high thwarted belongingness, even at the 90th percentile, unless they also reported high perceived burdensomeness.

“This study indicated that even among participants with high levels of thwarted belongingness (i.e., those at the 90th percentile in the sample), elevations in suicidal ideation were not evident unless high perceptions of burdensomeness were also present.”

• cites Van Orden, Witte, Gordon, Bender, & Joiner, 2008Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

The need to belong is the particular interpersonal need that drives the development of suicidal desire.

“we propose that the need to belong is the need central to the development of suicidal desire, consistent with the wealth of findings linking social connectedness to suicidal behavior.”

• AssumptionThe authors state this as an assumption: People die by suicide because they are capable of suicide and because they desire it.

Thwarted belongingness is a multidimensional construct.

“The theory also differs in that we propose that thwarted belongingness is a multidimensional construct.”

Available data indicate that agitation is a pernicious sign of elevated risk.

“Less research has been conducted on agitation, but available data indicate that agitation is a pernicious sign of elevated risk.”

• cites Table 1Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Thwarted belongingness may cause suicidal ideation when it occurs together with perceived burdensomeness.

“These data suggest that one condition under which thwarted belongingness may cause suicidal ideation is when it is experienced concurrently with perceptions of burdensomeness.”

Many studies have found independent links between measures of thwarted belongingness and suicide.

“However, numerous studies have documented independent associations between indices of thwarted belongingness and suicide.”

Consistent and robust support has been found for hopelessness and sleep disturbances as warning signs for suicide.

“Consistent and robust support has been found for hopelessness and sleep disturbances.”

• cites Table 1Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Each of the major theoretical perspectives on suicide is able to explain part of the landscape of suicidal behavior.

“Each of these theories is able to explain part of the landscape of suicidal behavior.”

Numerous studies have demonstrated associations between lethal suicidal behavior and facets of social isolation, including loneliness, social withdrawal, living alone, having few social supports, living in non-intact families, losing a spouse through death or divorce, and residing in a single prison cell.

“Numerous empirical studies (listed in Table 1) have demonstrated associations between lethal suicidal behavior and various facets of social isolation, including loneliness, social withdrawal, living alone and having few social supports, living in non-intact families, losing a spouse through death or divorce, and residing in a single prison cell.”

• cites Table 1Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

The absence of reciprocally caring relationships factor is proposed to produce six observable risk factors for lethal suicidal behavior: social withdrawal, low openness, single jail cell residence, domestic violence, childhood abuse, and familial discord.

“The absence of reciprocally-caring relationships factor is posited to give rise to six observable risk factors for lethal suicidal behavior: social withdrawal; low openness to experience; residing in a single jail cell; domestic violence; childhood abuse; and familial discord.”

Agitation, hopelessness, and sleep disturbances including nightmares have empirically demonstrated associations with lethal suicidal behavior.

“Several warning signs for suicide (i.e., signs of acute risk) have empirically-demonstrated associations with lethal suicidal behavior—agitation, hopelessness, and sleep disturbances including nightmares (see Table 1 for references).”

• cites Table 1Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Non-lethal suicide attempts greatly outnumber lethal attempts at a ratio of 25 to 1.

“Non-lethal suicide attempts greatly outnumber lethal attempts (at a ratio of 25 to 1)”

• cites American Association of Suicidology, 2006Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Loneliness and loss of a spouse, as additional aspects of social connectedness, also predict lethal suicidal behavior.

“Our review also indicated that other facets of social connectedness (e.g., loneliness and loss of a spouse) are also predictive of lethal suicidal behavior.”

The comprehensive models of suicidal behavior reviewed earlier are not precise enough to allow falsification or prediction of suicidal behavior.

“However, while the models described above are comprehensive and thereby able to account for the prevalence of suicidal behavior, they are not structured with a degree of precision that would allow for the falsification of the model and the prediction of suicidal behavior.”

With the exception of China, male suicides outnumber female suicides in every nation worldwide.

“With the exception of China, male suicides outnumber female suicides in every nation, worldwide (World Health Organization, 2003).”

• cites World Health Organization, 2003Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Across the lifespan, social isolation ranks among the most consistent and strongest predictors of suicidal thoughts, attempts, and lethal self-injury.

“As noted above, social isolation is one of the strongest and most reliable predictors of suicidal ideation, attempts, and lethal suicidal behavior across the lifespan.”

Social isolation, a severe form of thwarted belongingness involving few or no social relationships, has a robust association with suicide.

“A robust association has been documented between social isolation—a relatively severe manifestation of thwarted belongingness as it involves few to no social relationships—and suicide (as reviewed above).”

Under the theory, an unmet need to belong, termed thwarted belongingness, produces a desire for death, also called passive suicidal ideation.

“According to the theory, when this need is unmet—a state we refer to as thwarted belongingness—a desire for death develops (also referred to in the suicidology and clinical literature as passive suicidal ideation).”

• AssumptionThe authors state this as an assumption: People die by suicide because they are capable of suicide and because they desire it.

In the authors' laboratory study, self-reported thwarted belongingness showed a significant linear relationship with suicidal ideation among participants who also reported high perceived burdensomeness.

“Research from our laboratory group demonstrated a significant linear relationship between self-reported thwarted belongingness and suicidal ideation among participants who also endorsed high levels of perceived burdensomeness (Van Orden, Witte, Gordon, Bender, & Joiner, 2008).”

• cites Van Orden, Witte, Gordon, Bender, & Joiner, 2008Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

The authors propose that social connectedness variables relate to suicide because they signal that a basic human psychological need-the need to belong-is not met.

“We propose that these social connectedness variables are associated with suicide because they are observable indicators that a fundamental human psychological need is unmet; this need is described by Baumeister and Leary (1995) as the “need to belong” (p. 1).”

• cites Baumeister and Leary (1995) sourceNot checked — no full text of the source

Individuals who have experienced childhood abuse, military combat, homelessness, and incarceration are at elevated risk for lethal suicidal behavior.

“studies listed in Table 1 indicate that individuals who have experienced childhood abuse, military combat, homelessness, and incarceration are at elevated risk for lethal suicidal behavior”

• cites Table 1Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Prolonged thwarted belongingness makes suicidal ideation more likely.

“Thus, we propose that when thwarted belongingness is prolonged, suicidal ideation is more likely to result.”

• AssumptionThe authors state this as an assumption: Thwarted belongingness is a dynamic cognitive-affective state rather than a stable trait, shaped by interpersonal and intrapersonal factors, and it varies over time.
• AssumptionThe authors state this as an assumption: The need to belong is dimensional rather than categorical.

Chronicity appears to be an important dimension along which thwarted belongingness relates to psychological and health outcomes.

“These data suggest that a significant parameter along which thwarted belongingness may vary with regards to psychological/health outcomes is chronicity, as chronic loneliness was the key variable in the two preceding studies.”

Individuals who die by suicide present with numerous risk factors, rather than a single risk factor in isolation.

“individuals who die by suicide present with numerous risk factors, rather than a single risk factor in isolation (Maris, Berman, & Maltsberger, 1992)”

• cites Maris, Berman, & Maltsberger, 1992Not checked — no full text of the source

Empirical work has not directly tested how much thwarting of the need to belong is required for suicidal ideation to occur.

“Empirical studies have not directly examined this question, but data on the association between thwarted belongingness and other deleterious health outcomes speak to this question.”

Fearlessness about suicide can be operationalized with item 14 of the Beck Suicide Scale, where responses two and three indicate reduced fear.

“fearlessness about suicide can be measured using the Beck Suicide Scale (Beck & Streer, 1991) item number 14, with responses two and three indicating reduced fear”

• cites Beck & Streer, 1991Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

The interpersonal theory extends evolutionary fear models by proposing that humans are biologically prepared to fear suicide because suicidal behavior exposes them to cues long linked with threats to survival.

“The Interpersonal Theory draws upon—and extends—evolutionary models of fear and anxiety by proposing that humans are biologically prepared to fear suicide because suicidal behavior involves exposure to stimuli and cues that have long been associated with threats to survival.”

Having human connections is not by itself enough to meet the need to belong.

“the presence of human connections does not in itself satisfy the need to belong”

The theory is consistent with the markedly higher suicide rates in incarcerated and recently incarcerated populations.

“in this way, the theory is consistent with the fact that markedly elevated rates of suicide are found in incarcerated (and recently incarcerated) populations”

Expectations about pain, physiological habituation to pain, and cognitive appraisals of how tolerable pain is are proposed as key determinants of tolerance for the pain of a specific suicide method.

“We propose that both expectations about pain-to-be-experienced (e.g., “I won’t feel anything once I pull the trigger”), physiological habituation to physical pain sensations, and cognitive appraisals of the tolerability of expected/experienced pain are key factors in determining individuals’ tolerance for the pain involved in a specific suicide method.”

Childhood maltreatment and mental disorders are relevant to the development of both thwarted belongingness and perceived burdensomeness.

“However, these risk factors are relevant to the development of both constructs.”

Repeated practice and exposure can make the painful and fearful parts of self-harm less aversive, enabling increasingly painful, damaging, and lethal self-harm.

“through repeated practice and exposure, an individual can habituate to the physically painful and fearful aspects of self-harm, making it possible for him or her to engage in increasingly painful, physically damaging, and lethal forms of self-harm.”

If the process continues long enough, the opponent process becomes strong enough that the observed emotional experience shifts from negative to less negative to positive.

“If the process is continued long enough, eventually the strength of the opponent process will be such that the valence of the observed emotional experience shifts from negative to less negative to positive.”

• cites Solomon & Corbit, 1974 sourceNot checked — no full text of the source

Unlike opponent process theory, the interpersonal theory proposes that the primary process also weakens.

“However, the Interpersonal Theory differs in that it includes a proposal that the primary process also weakens.”

People whose need to belong was thwarted did not engage in affiliative behavior when the available affiliation target had caused the thwarting or was unavailable for in-person interaction.

“The authors found that those with thwarted needs to belong did not tend to engage in affilitative behaviors under two conditions: 1) if the person with whom affiliation could be increased was the person who caused the lowered belongingness (i.e., someone who rejected the participant) or 2) if the persons with whom affiliation could be increased would not be available for in-person interactions.”

• cites Maner, DeWall, Baumeister, & Schaller, 2007Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

The self-hate dimension of perceived burdensomeness has three observable indicators linked to lethal suicidal behavior: low self-esteem, self-blame and shame, and agitation.

“The other dimension of perceived burdensomeness is the affectively-laden construct of self-hate, with three corresponding observable indicators with empirically-demonstrated associations with lethal suicidal behavior: low self-esteem; self-blame and shame; and the mental state of agitation”

The latter finding suggests that elevated pain tolerance is likely specific to suicidal behavior rather than to physical injury in general.

“The latter finding indicates that elevated pain tolerance is likely specific to suicidal behavior, rather than physical injury more generally.”

The authors propose that childhood maltreatment and mental disorders increase suicide risk through their links to both thwarted belongingness and perceived burdensomeness.

“Thus, we posit that these risk factors increase risk for suicide through their relationship with both thwarted belongingness and perceived burdensomeness.”

The wish to make others better off is a more common reason for suicide attempts than for self-harm without suicidal intent.

“Similar to perceiving that one is a burden, the desire to “make others better off” was shown to be a more common reason given for suicide attempts versus episodes of self-harm without suicidal intent (Brown, Comtois, & Linehan, 2002)”

• cites Brown, Comtois, & Linehan, 2002 sourceNot checked — no full text of the source

Through repeated practice, an experience that was originally painful or fear-inducing may become less frightening and a source of emotional relief, making the person capable of behaviors that were previously painful and frightening.

“through repeated practice, what was originally a painful and/or fear-inducing experience (i.e., self-injury) may become less frightening as well as a source of emotional relief, thereby rendering individuals capable of engaging in what were previously painful and frightening behaviors.”

Agitation may signal self-hatred and anguish intense enough to have physiological manifestations.

“the mental state of agitation (in part, because it indicates that an individual may be experiencing a degree of self-hatred and anguish that is so elevated as to manifest physiologically).”

The liability dimension of perceived burdensomeness is proposed to produce observable risk factors for lethal suicidal behavior, including distress from unemployment, distress from incarceration, homelessness, serious physical illness, and statements in notes or communications that one is expendable, unwanted, or a burden.

“The liability factor is posited to give rise to six observable risk factors for lethal suicidal behavior (citations for the elevation of risk for lethal attempts are provided in Table 1): distress caused by unemployment”

• cites Table 1Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

In one study, people who reported past serious suicidal ideation but had not attempted suicide reported more fear of suicide than people with serious ideation who had attempted.

“individuals who reported a history of “past serious ideation” about suicide (p. 280) but had not attempted suicide reported higher levels of fear of suicide compared to individuals with serious ideation who had acted on this ideation through suicidal behaviors (Linehan, Goodstein, Nielsen, & Chiles, 1983).”

• cites Linehan, Goodstein, Nielsen, & Chiles, 1983 sourceNot checked — no full text of the source

This method-specific view can explain data showing that method substitution usually does not occur.

“In this way, we are able to provide an explanation for data indicating that method substitution does not typically occur.”

• AssumptionRests on an assumption: Method substitution does not typically occur when access to a means for suicide is blocked.

Perceived burdensomeness toward multiple others, rather than toward one person, may be especially harmful.

“These studies indicate that it may be that perceptions of burdensomeness on multiple others, rather than on a single individual, that may be particularly deleterious.”

This item is strongly associated with a self-report measure of acquired capability, with r = .79.

“this item is strongly associated (i.e., r = .79) with a self-report measure of acquired capability (Van Orden, Witte, Gordon, Bender, & Joiner, 2008).”

• cites Van Orden, Witte, Gordon, Bender, & Joiner, 2008Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

This produces a net change in the observed response toward the opponent process's valence, which appears behaviorally as habituation.

“This results in a net change in the observed response to be more similar to the valence of the opponent process, which behaviorally manifests as habituation.”

• cites Solomon & Corbit, 1974 sourceNot checked — no full text of the source

The interpersonal theory applies opponent process ideas to self-harm by treating fear and pain as the primary effects of painful or provocative stimuli and relief and analgesia as the opponent processes.

“The Interpersonal Theory involves an application of Solomon and Corbit’s (1974) ideas to self-harm behaviors such that that the primary effect of painful and provocative stimuli (e.g., self harm) is fear and pain and that the opponent processes are relief and analgesia.”

• cites Solomon & Corbit’s (1974) sourceNot checked — no full text of the source

According to the theory, people can acquire the capability for suicide, made up of greater physical pain tolerance and less fear of death, through habituation and opponent processes after repeated exposure to painful or fear-inducing experiences.

“it is possible to acquire the capability for suicide, which is composed of both increased physical pain tolerance and reduced fear of death, through habituation and activation of opponent processes, in response to repeated exposure to physically painful and/or fear-inducing experiences.”

Fear of suicide is one category of reasons people give for not engaging in suicidal behavior.

“Fear of suicide is one category of reasons that individuals give when asked why they do not engage in suicidal behavior (Linehan, Goodstein, Nielsen, & Chiles, 1983).”

• cites Linehan, Goodstein, Nielsen, & Chiles, 1983 sourceNot checked — no full text of the source

Family conflict, unemployment, and physical illness are among the risk factors for suicide with the strongest support for an association.

“Family conflict, unemployment, and physical illness were three of the risk factors for suicide (discussed above) with the most robust support for their association with suicide.”

A psychological autopsy study of terminal cancer patients who died by suicide found that self-perceived burdensomeness was a key characteristic likely contributing to suicidal desire.

“A psychological autopsy study of terminal cancer patients who died by suicide indicated that self-perceptions of being a burden on others was a key characteristic likely contributing to desire for suicide (Filiberti, Ripamonti, Totis, Ventafridda, De Conno, Contiero, et al., 2001).”

• cites Filiberti, Ripamonti, Totis, Ventafridda, De Conno, Contiero, et al., 2001Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Suicidal preschoolers, compared with preschoolers who have behavior problems, are more likely to be unwanted by their parents.

“Similarly, suicidal preschoolers (compared to preschoolers with behavior problems) have been shown to be more likely to be unwanted by their parents (Rosenthal & Rosenthal, 1984).”

• cites Rosenthal & Rosenthal, 1984 sourceNot checked — no full text of the source

Even people who seem most isolated usually still have some connection to others, such as estranged relatives, clinicians, or neighbors.

“even the most isolated individuals typically possess some degree of connection to others (e.g., estranged family members, health care providers, neighbors)”

According to the theory, the common proximate factor that either blocks or enables lethal or near-lethal suicidal behavior across methods is a cognitive appraisal that the pain of the chosen method is tolerable.

“the common and proximate factor among all methods that serves as either a barrier or facilitator of lethal (or near lethal) suicidal behavior is the presence of a cognitive appraisal that the pain involved in the chosen method of suicide is tolerable.”

The pain tolerance needed for lethal or near-lethal suicidal behavior is likely highly method-specific, so tolerance gained for cutting does not necessarily transfer to methods such as jumping.

“this construct is likely highly method-specific, thus someone gaining the requisite pain tolerance to engage in cutting behaviors will not necessarily have gained the same tolerance for other methods, such as jumping.”

Perceived expendability within the family correlates positively with suicidal behavior in adolescents.

“In a direct test of Sabbath’s theory, perceptions of expendability in the family were found to be positively correlated with suicidal behavior in adolescents (Woznica & Shapiro, 1990).”

• cites Woznica & Shapiro, 1990 sourceNot checked — no full text of the source

Among high-risk psychiatric patients, statements about feeling like a burden significantly increased suicide risk over a 60-day follow-up.

“A prospective study following psychiatric patients at high risk for suicide found that statements about feeling like a burden on others significantly elevated risk for suicide during a 60-day follow-up period after an evaluation (Motto & Bostrom, 1990).”

• cites Motto & Bostrom, 1990Not checked — no full text of the source

The authors propose that a heightened likelihood of perceiving oneself as a burden on others is the shared link between family conflict, unemployment, and physical illness that explains their associations with suicide.

“We propose that the elevated likelihood of developing perceptions of burdensomeness on others is the common thread between family conflict, unemployment, and physical illness that can account for the associations with suicide.”

Perceived expendability characterizes suicidal adolescents.

“Recall also that perceptions of expendability have been shown to characterize suicidal adolescents (Woznica & Shapiro, 1990).”

• cites Woznica & Shapiro, 1990 sourceNot checked — no full text of the source

Suicidal children are significantly more likely to have been born from unwanted pregnancies.

“Converging results were found in a sample of preschoolers: suicidal children were significantly more likely to be the product of “unwanted” pregnancies (Rosenthal & Rosenthal, 1984).”

• cites Rosenthal & Rosenthal, 1984 sourceNot checked — no full text of the source

People with recent suicidal behavior also show higher pain tolerance than people admitted to an emergency room for accidental injuries.

“and compared to individuals admitted to the emergency room due to accident injuries (Orbach, Stein, Palgi, Asherov, HarEven, & Elizur, 1996).”

• cites Orbach, Stein, Palgi, Asherov, HarEven, & Elizur, 1996Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

People with recent suicidal behavior show higher physical pain tolerance than non-suicidal psychiatric patients and community individuals, as measured by electric shock and thermal pain.

“individuals with recent suicidal behavior demonstrate elevated physical pain tolerance (as measured by electric shock and thermal pain) compared to non-suicidal psychiatric patients and individuals in the community (Orbach, Mikulincer, King, Cohen, & Stein, 1997; Orbach, Palgi, Stein, HarEven, LotemPeleg, Asherov, et al., 1996)”

• cites Orbach, Mikulincer, King, Cohen, & Stein, 1997Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

• cites Orbach, Palgi, Stein, HarEven, LotemPeleg, Asherov, et al., 1996Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

If childhood maltreatment and mental disorders make people more likely to see themselves as unwanted or expendable, they may also raise perceived burdensomeness.

“Insofar as childhood maltreatment and mental disorders predispose individuals to perceive that they are unwanted or expendable, these experiences may also elevate risk for perceptions of burdensomeness.”

A relationship can provide some sense of belonging even when the person also strongly perceives himself or herself as a burden to others.

“In this instance, a degree of belongingness is evident in the presence of strong perceptions of burdensomeness.”

Prior research has found a moderate significant correlation between thwarted belongingness and perceived burdensomeness, with a reported zero-order correlation of .58.

“prior studies indicating a significant correlation of moderate magnitude between the two constructs (e.g., zero order correlation coefficient of .58; Van Orden, Witte, Gordon, Bender, & Joiner, 2008).”

• cites Van Orden, Witte, Gordon, Bender, & Joiner, 2008Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

More serious suicidal ideation has been shown to predict higher levels of self-administered shock.

“more serious levels of suicidal ideation have been shown to predict higher levels of self-administered shock (Berman & Walley, 2003).”

• cites Berman & Walley, 2003 sourceNot checked — no full text of the source

Increases in positive affect have been observed after self-harm without suicidal intent.

“it has been observed that increases in positive affect may occur subsequent to self-harm without suicidal intent (Brain, Haines, & Williams, 1998; Muehlenkamp, Engel, Wadeson, Crosby, Wonderlich, Simonich, et al., 2009)”

• cites Brain, Haines, & Williams, 1998Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

• cites Muehlenkamp, Engel, Wadeson, Crosby, Wonderlich, Simonich, et al., 2009Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

More distal risk factors affect suicidal desire by raising thwarted belongingness, perceived burdensomeness, or both.

“The theory involves the proposal that other more distal risk factors exert their influence on desire for suicide by increasing levels of thwarted belongingness, perceived burdensomeness, or some combination of the two.”

Sabbath's theory cannot explain why most adolescents who believe their families would be better off without them do not die by suicide.

“However, Sabbath’s theory does not account for the fact that the majority of youth who perceive that their families would be better of without them do not die by suicide.”

More severe thwarted belongingness may lead to more severe self-defeating behavior, with suicidal behavior as an example.

“The data from the cited studies suggest that this more extreme form of thwarted belongingness may result in a more extreme form of self-defeating behavior, of which suicidal behaviors are an example.”

Unemployment should raise suicide risk only when its stress leads to perceptions that one is a liability to oneself and others.

“unemployment should elevate risk for suicide, according to the Interpersonal Theory, only when the stress of unemployment results in perceptions that one is a liability to oneself and others”

The belief that someone wants one dead distinguishes suicidal from non-suicidal individuals.

“and the belief that someone wishes one dead was shown to differentiate between suicidal and non-suicidal individuals (Rosenbaum & Richman, 1970).”

• cites Rosenbaum & Richman, 1970 sourceNot checked — no full text of the source

In the same study, stronger perceived burdensomeness in notes predicted more lethal means among those who died.

“In addition, in the same study, greater perceptions of burdensomeness in the notes predicted the use of more lethal means among the sample of notes from individuals who died.”

• cites Joiner, Pettit, Walker, Voelz, Cruz, Rudd, et al., 2002Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Hopelessness is associated with suicidal behavior.

“This finding is certainly supportive of the notion that hopelessness is associated with suicidal behavior.”

An examination of suicide notes found higher perceived burdensomeness in notes from people who died by suicide than in notes from people who attempted but survived.

“an examination of the content of suicide notes found higher levels of perceived burdensomeness in notes from individuals who died by suicide compared to notes from individuals who attempted but survived (Joiner et al., 2002).”

• cites Joiner et al., 2002Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Capability for suicide is conceptualized as something gained over time.

“while the capability for suicide is conceptualized as a capability that is gained over time”

The higher firearm use among veterans is notable because this group has extensive firearm exposure, giving many opportunities to habituate to the fearsome aspects of firearms.

“the increased risk for use of firearms is notable given that this population has extensive exposure to firearms, thus providing ample opportunities to habituate to the fearsome aspects of the use of firearms.”

Individuals high on both perceived burdensomeness and acquired capability were rated at highest suicide risk by clinicians.

“In line with predictions, the form of the interaction indicated that individuals high on both perceived burdensomeness and acquired capability were rated at highest risk for suicide by clinicians.”

• cites Van Orden, Witte, Gordon, Bender, & Joiner, 2008, Study 3Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

A study of military personnel found that branch of service was associated with a specific suicide method: guns for Army, hanging or knots for Navy, and falling or heights for Air Force.

“a study on military personnel found that the branch of service (e.g., Army vs. Navy) was associated with a specific method of suicide (i.e., guns for Army; hanging/knots for Navy; falling/heights for Air Force).”

These results held after controlling for current suicidal ideation, age, gender, and depressive symptoms.

“These results persisted after controlling for potentially confounding variables, including current level of suicidal ideation, age, gender, and depressive symptoms.”

• cites Van Orden, Witte, Gordon, Bender, & Joiner, 2008Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

In clinical outpatients, perceived burdensomeness and acquired capability interacted significantly in predicting clinician-rated suicide risk, above depression, gender, and age.

“Consistent with Hypothesis Four, results indicated a significant interaction between perceived burdensomeness and acquired capability in the prediction of clinician-rated risk for suicide, above and beyond the effects of other risk factors (i.e., depression scores, gender, and age).”

• cites Van Orden, Witte, Gordon, Bender, & Joiner, 2008, Study 3Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Among people with passive suicidal thoughts, most do not go on to experience active suicidal ideation involving thoughts of killing themselves.

“The literature on suicide indicates that among those who have passive thoughts of suicide (e.g., “I would be better off dead”), most will not experience active suicidal ideation involving thoughts of killing themselves (Thomas, Crawford, Meltzer, & Lewis, 2002).”

• cites Thomas, Crawford, Meltzer, & Lewis, 2002 sourceNot checked — no full text of the source

One study found that people who reported more painful and provocative experiences also reported higher acquired capability scores.

“one study found that individuals who reported engaging in more painful and provocative experiences (e.g., shoplifting, promiscuous sex, played contact sports, got a piercing, shot a gun, intentionally hurt animals, physical fights, jumped from high places) also reported higher acquired capability scores (Van Orden, Witte, Gordon, Bender, & Joiner, 2008).”

• cites Van Orden, Witte, Gordon, Bender, & Joiner, 2008Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Limiting access to lethal means may block acquired capability and thereby reduce suicide rates.

“factors such as limiting access to lethal means may serve to block acquired capability, thus reducing rates of suicide.”

A series of studies on 'pulling together' after positive collective experiences, specifically sporting events, supported the relationship between thwarted belongingness and suicidal desire.

“The relationship between thwarted belongingness and suicidal desire was also supported by a series of studies investigating the phenomenon of “pulling together” after positive collective experiences, in this case, sporting events (Joiner, Hollar, & Van Orden, 2006).”

• cites Joiner, Hollar, & Van Orden, 2006 sourceNot checked — no full text of the source

A review of suicide risk factors indicates that a past suicide attempt is one of the strongest and most reliable predictors of suicidal behavior.

“Our review of risk factors for suicide indicates that a history of a past suicide attempt is another of the strongest and most reliable predictors of suicidal behavior”

In an ethnically diverse community sample of young adults, those low on both family support and mattering to others had the most severe suicidal ideation, controlling for six-month and lifetime depression.

“In the second study (Joiner, Van Orden, Witte, Selby, Ribeiro, & Lewis, in press), using an ethnically diverse community sample, young adults with low levels of both family support (cf. low belongingness) and mattering to others (cf. perceived burdensomeness) demonstrated the most severe levels of suicidal ideation, while including both six-month and lifetime histories of depression as covariates”

• cites Joiner, Van Orden, Witte, Selby, Ribeiro, & Lewis, in pressNot matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

The Beck Hopelessness Scale with a cut-off of 9 predicts both lethal and non-lethal suicide attempts.

“A meta-analytic review showed that the Beck Hopelessness Scale (BHS; (Beck, Weissman, Lester, & Trexler, 1974), using a cut-off score of 9, is predictive of both lethal and non-lethal suicide attempts (McMillan, Gilbody, Beresford, & Neilly, 2007).”

• cites McMillan, Gilbody, Beresford, & Neilly, 2007 sourceNot checked — no full text of the source

The construct of acquired capability offers a framework for understanding the complex links between past attempts and future suicidal behavior.

“The construct of acquired capability provides a framework for understanding the complex relations between a history of past attempts and risk for future suicidal behavior.”

High levels of both thwarted belongingness and perceived burdensomeness were most likely to translate into suicide attempts when acquired capability was higher.

“Results indicated that the combination of high levels of both thwarted belongingness and perceived burdensomeness was most likely to translate into suicide attempts in the presence of higher levels of acquired capability (i.e., greater numbers of past attempts).”

• cites Joiner et al., 2009, Study 2Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

According to the theory, the most direct but not the only route to acquiring capability for suicide is engaging in suicidal behavior, including attempts, aborted attempts, or practicing and preparing for suicide.

“the most direct route (but not the only route) to acquiring the capability for suicide (i.e., the most potent painful and provocative experience) is by engaging in suicidal behavior, either through suicide attempts, aborted suicide attempts (preparing for the attempt and nearly carrying it out), or practicing/preparing for suicidal behavior”

Risk factors shown in Figure 4-childhood maltreatment, clustering, combat exposure, impulsivity, and previous suicide attempts-are proposed to raise risk for lethal suicidal behavior because they are physically painful or frightening enough to engage habituation and opponent processes related to self-harm.

“The risk factors depicted in Figure 4—childhood maltreatment, clustering, combat exposure, impulsivity, and previous suicide attempts—are posited to increase risk for lethal suicidal behavior because they are physically painful and/or sufficiently frightening to engage habituation and opponent processes with regards to the pain and fear involved in self-harm.”

The BHS specificity was 0.42 for both fatal and non-fatal suicide attempts.

“Nevertheless, the specificity of the BHS (i.e., the probability of a negative test result among those who did not engage in suicidal behavior) was 0.42 for both fatal and non-fatal suicide attempts.”

• cites McMillan, Gilbody, Beresford, & Neilly, 2007 sourceNot checked — no full text of the source

Nearly 60% of those who did not make a suicide attempt scored above 9 on the BHS.

“This indicates that nearly 60% of those who did not make a suicide attempt had a cut-off score above 9 on the BHS.”

When low belongingness and perceived burdensomeness are held simultaneously, risk for suicidal desire is elevated beyond the effects of depression.

“Findings from these studies suggest that when people hold two psychological states in their minds simultaneously—low belongingness and perceived burdensomeness—risk for the development of suicidal desire is elevated (and this occurs beyond the effects of depression).”

In young adults in a suicidal crisis, the three-way interaction of thwarted belongingness, perceived burdensomeness, and acquired capability predicted whether the crisis involved a suicide attempt.

“Results were consistent with the theory and indicated that the three-way interaction of thwarted belongingness, perceived burdensomeness, and acquired capability (measured by number of past suicide attempts) predicted whether or not participants’ current suicidal crises involved suicide attempts.”

• cites Joiner et al., 2009, Study 2Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Approximately 80% of people who engaged in serious suicidal behavior score above the BHS cut-off.

“This indicates that approximately 80% of people who engaged in serious suicidal behavior score above this cut-off point on the BHS.”

The authors also propose that the link between how planful a suicide attempt is and how lethal it is relates to habituation to painful and provocative experiences.

“Regarding the relationship between the planfulness of suicide attempts and their lethality, we propose that this is also related to habituation to painful and provocative experiences.”

Combat exposure, which involves fear of one's own possible death and killing others, is a relatively direct pathway to acquired capability according to the theory.

“Combat exposure, which involves exposure to the fear of one’s own possible death, as well as killing others, represents a relatively direct pathway, according to the theory.”

A psychological autopsy study found that retrospectively assessed acquired capability discriminated between living controls and people who died by suicide in a military sample.

“A psychological autopsy study found that retrospectively assessed levels of acquired capability—sample items included the prior engagement in suicide-preparatory behaviors, past suicide attempts, and problems with impulsivity—discriminated between living controls and those who died by suicide in a military sample (Nademin, Jobes, Pflanz, Jacoby, Ghahramanlou-Holloway, Campise, et al., 2008).”

• cites Nademin, Jobes, Pflanz, Jacoby, Ghahramanlou-Holloway, Campise, et al., 2008Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Besides prior suicidal behavior, less potent pathways to acquired capability may exist through other fear-inducing, risky behaviors.

“In addition to previous suicidal behavior, other less potent pathways may also exist through the experience of other fear-inducing, risky behaviors.”

In undergraduates, the most severe suicidal desire was reported by those with the most severe levels of both thwarted belongingness and perceived burdensomeness, compared with those severe on only one, above age, gender, and depression.

“In the first study (Van Orden, Witte, Gordon, Bender, & Joiner, 2008), the most severe levels of suicidal desire (operationalized as suicidal ideation on the Beck Suicide Scale) were reported by undergraduates at the most severe levels (in the sample) on both thwarted belongingness and perceived burdensomeness, relative to individuals with severe levels of only thwarted belongingness or perceived”

• cites Van Orden, Witte, Gordon, Bender, & Joiner, 2008Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

One study among methadone maintenance patients at an urban university hospital examined the relation between self-reported thwarted belongingness and likelihood of a past suicide attempt.

“One study examined the relation between thwarted belongingness measured by self-report and likelihood of having a past suicide attempt (Conner, Britton, Sworts, & Joiner, 2007) among methadone maintenance patients at an urban university hospital.”

• cites Conner, Britton, Sworts, & Joiner, 2007 sourceNot checked — no full text of the source

The theory would be falsified if studies did not find independent associations of both thwarted belongingness and perceived burdensomeness with suicidal ideation or behaviors.

“The theory could be falsified if studies do not document independent associations for both thwarted belongingness and perceived burdensomeness with suicidal ideation or behaviors.”

The construct of acquired capability offers a parsimonious explanation for these facts: impulsive or aggressive people are more likely to engage in painful and provocative behaviors.

“The construct of acquired capability provides a parsimonious explanation for this array of facts: impulsive and/or aggressive individuals are more likely to engage in behaviors that are painful and provocative (e.g., physical fights, injecting drugs).”

• AssumptionRests on an assumption: Impulsive people do not necessarily make impulsive suicide attempts; people who have engaged in more impulsive behaviors have been shown to engage in more prior planning for suicide attempts and use more medically serious methods.

Theories of suicide that focus only on suicidal desire have difficulty accounting for method substitution data and many other findings.

“Theoretical accounts of suicide that focus only on suicidal desire struggle to account for these data on method substitution (and for many other findings too).”

Available theories mostly do not address both intra-individual and inter-individual factors.

“In addition, as noted by Prinstein (2008), available theories do not, for the most part, address both intra-individual and inter-individual factors.”

• cites Prinstein (2008) sourceNot checked — no full text of the source

Extreme fear of abandonment in BPD likely relates to thwarted belongingness.

“Another hallmark feature of BPD is extreme fear of abandonment (American Psychiatric Association, 2000), a symptom that likely relates to thwarted belongingness.”

• cites American Psychiatric Association, 2000Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Repeated non-lethal self-injurious behavior in BPD represents a relatively direct pathway to acquired capability for lethal self-injury.

“A hallmark feature of BPD is repeated non-lethal, self-injurious behavior, which according to the theory represents a relatively direct pathway to the acquired capability to lethal self-injury.”

Risk factors such as mental disorders and childhood abuse confer risk for suicidal behavior indirectly by increasing or indicating thwarted belongingness, perceived burdensomeness, and pain/provocation.

“risk factors—such as mental disorders and childhood abuse—confer risk for suicidal behavior indirectly by increasing—or indicating the presence of—experiences of thwarted belongingness, perceived burdensomeness, and pain/provocation.”

Other pathways to suicidal behaviors are possible.

“Thus, other pathways to suicidal behaviors are possible.”

Empirically supported risk factors for suicide elevate risk because they indicate thwarted belongingness, perceived burdensomeness, or acquired capability.

“Figures 2–4 depict the hypothesis that empirically-supported risk factors for suicide elevate risk because they are indicators of thwarted belongingness, perceived burdensomeness, or the acquired capability.”

The theory explains difficult epidemiological facts about suicide, including gender distribution and prevalence of different forms of suicidal behavior, which available theories cannot fully explain.

“The theory also provides explanations for heretofore difficult to explain epidemiological facts about suicide – including the gender distribution and prevalence of different forms of suicidal behavior – facts that available theories are unable to explain fully.”

Anorexia Nervosa is associated with a high suicide rate.

“Consider also that Anorexia Nervosa is associated with a high suicide rate (Keel, Dorer, Eddy, Franko, Charatan, & Herzog, 2003).”

• cites Keel, Dorer, Eddy, Franko, Charatan, & Herzog, 2003Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

The simultaneous presence of the theory's three conditions is sufficient to result in lethal or near-lethal suicide attempts.

“The theory involves three conditions that, when present simultaneously, are sufficient to result in lethal (or near lethal) suicide attempts.”

Interventions that directly or indirectly address perceived burdensomeness and thwarted belongingness should produce the best outcomes among suicidal individuals.

“According to the theory, interventions that directly or indirectly address perceived burdensomeness and thwarted belongingness should produce the best outcomes among suicidal individuals.”

Because each of the three conditions is relatively rare and their confluence rarer, the theory is consistent with the rarity of suicidal behavior.

“As each of these conditions is relatively rare, and their confluence more so, the theory is consistent with the rarity of suicidal behavior itself.”

• AssumptionRests on an assumption: Each of the theory's three conditions is relatively rare, and their confluence is rarer.

The high rate of suicidal behavior in AN may be partly accounted for by pain and provocation experiences central to the disorder that may foster acquired capability.

“This study suggests that the high rate of suicidal behavior among individuals with AN may be accounted for, in part, by experiences of pain and provocation that are a central component of the disorder (e.g., self-starvation) and that may foster acquired capability for suicidal behavior.”

Individuals with BPD often engage in self-injurious behavior during threatened or real abandonment episodes.

“In fact, it is often during threatened or real abandonment episodes when individuals with BPD engage in self-injurious behavior (American Psychiatric Association, 2000).”

• cites American Psychiatric Association, 2000Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

The three-way interaction predicted suicide attempts above depression, hopelessness, and borderline personality disorder features.

“Results were obtained above and beyond the contribution of numerous documented risk factors for suicidality, including depression, hopelessness, and borderline personality disorder features.”

• cites Joiner et al., 2009, Study 2Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.