Suicidal behavior is not a "spur of the moment" action

by Michael D. Anestis, M.S.

In the research world, the more times we see a result happen, the more confident we become that it represents a real phenomenon rather than pure chance.  This approach keeps us from getting overly excited about one significant result or overly confused by one non-significant result.  Over time, one finding that has been repeatedly supported and, as such, appears to represent a true phenomenon, is a significant relationship between impulsivity and suicidal behavior.  This finding has, by no means been supported without fail, but it has been supported enough times using enough different measures of both impulsivity and suicidal behavior that little debate remains regarding whether the relationship is real.

For those of you who are unfamiliar with the concept of impulsivity, it is loosely defined as the tendency to act without consideration of the implications and consequences of that action.  That being said, a number of competing definitions of the term exist and we have covered those in previous posts (click here for an example).  The general point though, regardless of the sloppiness of a term like "impulsivity," is that data linking the idea to suicidal behavior has prompted a widely held belief that suicidal behavior is often a "spur of the moment" decision rather than a highly planned action built up to over time.

This idea has intuitive appeal.  We've seen it in television and the movies - an individual was going along fine until something awful happened and, because in that moment they saw no other escape, they took their own life.  This decision is portrayed as something that had not occurred to the individual until that moment, as though it suddenly dawned on them that this opportunity existed, that an answer had been revealed. For generations, this has been a popular viewpoint held by many remarkably prolific psychologists, including many whose careers focus almost entirely on the concept of suicide.

At first glance, you might be wondering how, given the above information, I arrived at the title of this article: suicidal behavior is not a "spur of the moment" decision.  After all, there is an undeniable statistical link between impulsivity and suicidal behavior and a number of prominent researchers support the notion of impulsive suicide.  My first response is a quick reminder that a correlation between two variables does not tell us a whole lot about the relationship.  What it says in this case is that, as an individual demonstrates higher levels of trait impulsivity (a tendency, across their life, to engage in impulsive behaviors), the likelihood of their death by suicide increases.  What it does not say is that their death by suicide occurs in an impulsive fashion. In other words, there is every reason to believe that another variable related to both impulsivity and suicidal behavior explains the relationship.  We'll return to that point in a bit.

So...is there any evidence to support the notion that, despite a relationship between impulsivity and suicidal behavior, the action itself is not a "spur of the moment" action?  Absolutely.  In a wonderful study published in the Journal of Affective Disorders and conducted by a number of my colleagues at Florida State University (Witte, Merrill, Stellrecht, Bernert, Hollar, Schatschneider, & Joiner, 2008), the authors looked directly at this phenomenon.  I alluded to this study briefly at the end of 2009 when I published my commentary on the importance of providing condolence letters to the families of soldiers who die by suicide (click here for that article).  Using a sample from the Youth Risk Behavior Survey collected between 1993 and 2003, PBB guest author Tracy Witte and her colleagues (2008) looked at adolescents who had planned for a suicide attempt but did not actually attempt (n = 5,685), adolescents who did not plan but did attempt (n = 1,172), and individuals who both planned and attempted (n = 4,807).

What did they find?  Individuals who had planned without attempting were less impulsive than were individuals who attempted without planning and individuals who had both planned and attempted (this makes sense, given that attempt status is typically associated with impulsivity).  Importantly however, individuals who attempted without planning had lower impulsivity scores than those who had both planned and attempted.  In other words, the more impulsive you are, the more likely you are to plan before attempting.  Additionally, less than 25% of the suicide attempts in this sample were "impulsive," indicating that such a style is far from the norm.

Looking at those results, you might still think 25% is a fairly large number given the title of this article.  Fair enough.  To address that further, it helps to consider another important set of findings, which Witte and colleagues (2008) mentioned in the introduction of their study.  In 2001 and 2005, Baca-Garcia and colleagues found that the more impulsive a suicide attempt is, the less medically serious it tends to be.  In other words, the vast majority of suicide attempts involve significant planning and those that do not tend to be of lower severity.  Now, keep in mind that this does not mean that a lethal impulsive attempt never happens but rather that such an occurrence is extremely rare even relative to other styles of attempt, which statistically speaking are also fairly rare (even with an average of 32,000 deaths by suicide annually in the United States, which is a large raw number that requires significant attention but which represents a small fraction of the population).

So how can we explain all of this?  The most theoretically sound framework appears to be Joiner's (2005) interpersonal-psychological theory of suicidal behavior, which we have covered frequently on PBB.  The theory states that, in order to enact lethal self-harm, an individual must not only desire death by suicide but must also acquired the capability to do so.  The acquired capability is accrued through repeated exposure to painful and provocative events, which over time increase an individual's ability to tolerate physical pain and decreases an individual's fear of death.  Impulsive individuals, over the course of their lifetime, encounter a greater number of painful and provocative events and, in doing so, they develop the capability to engage in lethal suicide attempts.  Developing this ability, however, does not mean that they will engage in the behavior impulsively.  Rather, it simply means that, through their impulsive lifestyle, they have become less fearful of death and pain and that when they consider death by suicide, they are more likely to choose and utilize a lethal means.  They might think about suicide impulsively, with the thought entering their head suddenly in response to a negative event, but they are unlikely to actually make an attempt as quickly.  Instead, frequent bouts of ideation are likely to make them frequently contemplate specific ways in which they would consider attempting and how they might go about acquiring those means and enacting an attempt.  Their thoughts might not be recognized by anyone else around them and, as such, the attempt itself might seem to come from "out of the blue," but the fact that they did not talk about it (or that their words seemed to simply reflect a great amount of discomfort rather than a true desire for death) does not mean that they were not present for a long time, increasing in severity and becoming more specific over time.

Summary:

Without question, impulsivity is related to suicidal behavior.  That being said, the data do not support the notion that suicide attempts tend to occur on the "spur of the moment" without substantial planning.  In fact, a study by Witte and colleagues (2008) indicated that impulsive individuals tend to plan their attempts more than non-impulsive individuals and studies by Baca-Garcia and colleagues (2001, 2005) demonstrated that the more impulsive an attempt is, the less medically serious it tends to be.  Given that only 25% of the attempts in the Witte et al (2008) sample were considered impulsive and that such attempts have been shown in other studies to typically be less severe, this paints a very different picture than what many people have considered.  Rather than being the result of a sudden surge of discomfort and a desire to escape, suicidal behavior appears to be a process built up to over time, the result of substantial planning.  Seen through the lens of Joiner's (2005) interpersonal-psychological theory, this pattern reflects the importance of considering the acquired capability for suicide, which people build up to independent of whether they have any desire for death through the repeated experience of pain and provocation.

Importantly, these findings are not evidence that suicide never occurs impulsively, but rather that this is far from the norm.  Just because two variables are related to one another - in this case, impulsivity and suicidal behavior - does not mean that their relationship is as straight forward as we might intuitively believe.  In this case, the evidence supports a more indirect relationship: impulsivity causes individuals to engage in the types of behaviors and experiences likely to increase their acquired capability for suicide.  When and if such individuals ever experience the desire for suicide, they are thus more likely to actually enact lethal self-harm than are individuals without such a history of impulsive behaviors.  That being said, their attempts are likely to be highly thought out, with substantial planning and preparation, even if those activities are unknown to everyone around them.

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If you or anyone you know is experiencing thoughts of suicide, please dial 1-800-273-TALK, which is an anonymous and free service available 24 hours per day specifically to help with this type of situation.  If you are uncomfortable calling that number, please consider dialing 911 or going to a local emergency room.

If you would like to learn more about suicidal behavior and its treatment, we recommend the following items, all of which are available through our online store for scientifically-based psychological resources:

• Why People Die by Suicide by Thomas Joiner
  

• The Interpersonal Theory of Suicide: Guidance for Working With Suicidal Clients by Thomas Joiner, Kim Van Orden, Tracy Witte, and David Rudd
  

• Treating Suicidal Behavior: An Effective, Time-Limited Approach by David Rudd, Thomas Joiner, and Hasan Rajab

Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University