Cited by 158Bipolar Disorder and TreatmentSuicide and Self-Harm StudiesPersonality Disorders and Psychopathology

Cognitions in bipolar affective disorder and unipolar depression: imagining suicide

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Hales, Susie A, Deeprose, Catherine, Goodwin, Guy M, Holmes, Emily A·2011·Bipolar Disorders

Abstract

Hales SA, Deeprose C, Goodwin GM, Holmes EA. Cognitions in bipolar affective disorder and unipolar depression: imagining suicide. Bipolar Disord 2011: 13: 651–661. © 2011 The Authors. Journal compilation © 2011 John Wiley & Sons A/S. Objective: Bipolar disorder has the highest rate of suicide of all the psychiatric disorders. In unipolar depression, individuals report vivid, affect‐laden images of suicide or the aftermath of death (flashforwards to suicide) during suicidal ideation but this phenomenon has not been explored in bipolar disorder. Therefore the authors investigated and compared imagery and verbal thoughts related to past suicidality in individuals with bipolar disorder (n = 20) and unipolar depression (n = 20). Methods: The study used a quasi‐experimental comparative design. The Structured Clinical Interview for DSM‐IV was used to confirm diagnoses. Quantitative and qualitative data were gathered through questionnaire measures (e.g., mood and trait imagery use). Individual interviews assessed suicidal cognitions in the form of (i) mental images and (ii) verbal thoughts. Results: All participants reported imagining flashforwards to suicide. Both groups reported greater preoccupation with these suicide‐related images than with verbal thoughts about suicide. However, compared to the unipolar group, the bipolar group were significantly more preoccupied with flashforward imagery, rated this imagery as more compelling, and were more than twice as likely to report that the images made them want to take action to complete suicide. In addition, the bipolar group reported a greater trait propensity to use mental imagery in general. Conclusions: Suicidal ideation needs to be better characterized, and mental imagery of suicide has been a neglected but potentially critical feature of suicidal ideation, particularly in bipolar disorder. Our findings suggest that flashforward imagery warrants further investigation for formal universal clinical assessment procedures.

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Crossref · 10.1111/j.1399-5618.2011.00954.x

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  • This does not account for the role of imagery in cases when it deters individuals from engaging in self-harm or attempting suicide.

    “However, this does not account for the role of imagery in cases when it deters individuals from engaging in self-harm or attempting suicide (Hales et al., 2011; McEvoy et al., 2017).”

    From The Psychological Pathway to Suicide Attempts: A Strategy of Control Without Awareness (2021) · cites this paper as Hales et al., 2011

    The Discussion (page unavailable) says suicidal imagery can evoke fear as well as comfort and may reflect ambivalence about suicide. It does not say that imagery deters self-harm or suicide attempts, so the claimed behavioral effect is unsupported. (LLM, conf=0.76)

    Experimental — accuracy not yet measured
  • Some individuals allow themselves to experience reminders of goals that would be negatively impacted upon by their death from suicide.

    “In contrast, some individuals allow themselves to experience reminders of goals that would be negatively impacted upon by their death from suicide (Hales et al., 2011; Crane et al., 2012).”

    From The Psychological Pathway to Suicide Attempts: A Strategy of Control Without Awareness (2021) · cites this paper as Hales et al., 2011

    In “Suicidal images: flashforwards” (page unavailable), a participant imagined her children crying and said she could not act on suicide because of its effect on her family. This supports the idea that some people experience reminders of what their death would harm, but the paper does not establish that they deliberately allow those reminders or describe them as reminders of goals. (LLM, conf=0.82)

    Experimental — accuracy not yet measured
  • Mental imagery of suicide increases the likelihood of enactment as it acts as a form of cognitive rehearsal for the behaviour.

    “We hypothesize that mental imagery increases the likelihood of enactment as it acts as a form of cognitive rehearsal for the behaviour”
  • Individuals who are in crisis can experience imagery related to suicide, such as images of desired outcomes or unwanted consequences.

    “In addition, individuals who are in crisis can experience imagery related to suicide, such as images of desired outcomes or unwanted consequences (Hales et al., 2011).”
  • Both ideators and attempters experience suicide imagery, and imagery deters some individuals from engaging in self-harm and attempting suicide.

    “The role of these images may be complex in suicide, since both ideators and attempters experience suicide imagery, and imagery deters some individuals from engaging in self-harm and attempting suicide (Hales et al., 2011; McEvoy et al., 2017).”

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Research works printed but not linked: 1

  1. [17]First MB Spitzer RL Gibbon M Williams JBW Structured Clinical Interview for DSM-IV Axis I Disorders – Patient Edition (SCID-I/P, Version 2.0) 1996 New York Biometrics Research Department, New York State Psychiatric Institute

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Authors
Hales, S. A., Deeprose, C., Goodwin, G. M., & Holmes, E. A.
Affiliations
University of Oxford (GB)
Corresponding author
Hales, Susie A
Venue
Bipolar Disorders
Publisher
Wiley
Published
2011-11
Volume
13
Issue
7-8
Pages
651-661
ISSN
  • 1398-5647 (ISSN-L)
  • 1399-5618
OpenAlex
W2118935759
Cited by
157
References
37
Citations by year
2026: 7 · 2025: 11 · 2024: 13 · 2023: 20 · 2022: 9 · 2021: 12 · 2020: 11 · 2019: 11 · 2018: 11 · 2017: 7 · 2016: 13 · 2015: 13 · 2014: 6 · 2013: 6 · 2012: 6
FWCI
4.16
Type
journal article
Language
en
Open access
Locations
  • Bipolar Disorders (publishedVersion)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • ePrints Soton (University of Southampton) (acceptedVersion)
  • PEARL (University of Plymouth) (submittedVersion)
  • PEARL (University of Plymouth) (submittedVersion, other-oa)
Funders
  • Sanofi
  • Wellcome Trust (WT088217)
  • Lupina Foundation
  • National Institute for Health and Care Research (NF-SI-0510-10102)
  • Servier
  • Medical Research Council
  • Economic and Social Research Council
Topics
  • Health Sciences › Medicine › Psychiatry and Mental health › Bipolar Disorder and Treatment
  • Social Sciences › Psychology › Clinical Psychology › Suicide and Self-Harm Studies
  • Social Sciences › Psychology › Clinical Psychology › Personality Disorders and Psychopathology
Keywords
bipolar disorder, major depressive disorder, suicidal ideation, mental imagery, suicidal cognitions, suicide risk assessment
MeSH terms
Adult, Bipolar Disorder, Cognition Disorders, Depressive Disorder, Female, Humans, Imagination, Male, Middle Aged, Neuropsychological Tests, Psychiatric Status Rating Scales, Psychometrics, Surveys and Questionnaires, Suicide, Diagnostic and Statistical Manual of Mental Disorders

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