Section 1
Chapter
High-risk cognitive states
5 Gregory K. Brown and Kelly L. Green
High-risk cognitive states
A middle-aged man is brought to the emergency room
via ambulance after his wife comes home early to dis-
cover him unconscious with empty bottles of whisky
and prescription medication lying next to him. His
stomach is pumped and doctors are able to stabilize
him. He admits to a psychiatrist the next morning that
he attempted to kill himself and wanted to die and is
subsequently admitted to an inpatient psychiatric unit.
A critical question that his treatment team will be asking
over the course of his stay is: “What was he thinking?”
Understanding the types of thoughts, beliefs, and
cognitive processes that were experienced before,
during and following the suicidal crisis is critical for
formulating a treatment plan that is tailored to the
patient’s individual needs. In this chapter, cognition
and its role in suicide attempts and death by suicide
will be discussed by examining high-risk states for sui-
cide, particularly suicidal ideation, attentional fixation,
hopelessness, problem solving deficits, perfectionism,
and homicidal ideation. The state of the literature for
each of these risk factors will be briefly summarized and
recommendations for future research in this area will be
outlined.
Suicidal ideation
The most important cognitive risk factor to consider in
determining an individual’s risk of making a suicide
attempt or dying by suicide is suicidal ideation.
Although the field has yet to reach consensus on a stand-
ard nomenclature for suicide-related constructs, suicidal
ideation is commonly defined as thinking about, con-
templating, or planning for suicide (Crosby et al., 2011).
Suicidal ideation may include thoughts, beliefs, images,
voices, or other cognitions reported by the individual
about intentionally ending one’s own life. According
to the recent World Health Organization (WHO)
A Concise Guide to Understanding Suicide, ed. Stephen H. Koslow, Pedro Ruiz, and Charles B. Nemeroff. Published by
Cambridge University Press. © Cambridge University Press 2014.
42
Downloaded from https://www.cambridge.org/core. University of Birmingham, on 18 Nov 2019 at 12:10:05, subject to the Cambridge Core terms of use, available at
https://www.cambridge.org/core/terms. https://doi.org/10.1017/CBO9781139519502.007
Surveys, the 12-month prevalence rate for suicidal
ideation across 21 different countries is 2% (Borges
et al., 2010). Results from the National Comorbidity
Study in the United States suggest a lifetime prevalence
rate of 13.5% for suicidal ideation among individuals
between the ages of 15 and 54 (Kessler et al., 1999).
The construct of suicidal ideation can be thought of
as a continuum of increasing severity. The least severe
type of suicidal ideation occurs when an individual
wishes for death, but has no specific thoughts about
wanting to kill him- or herself. For example, a patient
experiencing these types of thoughts might say things
like “I wish I could go to sleep and not wake up.” The
next level of severity may include thoughts of killing
oneself, but without any intent to act on the thoughts
or any specific plan to carry out these thoughts. An
example of this type of ideation would be a patient
who says “I think about killing myself, but I haven’t
worked out a way to do it and I don’t think that I could
ever go through with it.” More severe forms of suicidal
ideation are those that involve an intent to act on these
thoughts with or without a specific plan to do so. An
individual who has suicidal ideation with a plan but no
intent might describe thinking about killing themselves
via overdose, but then state that they have no intention
to act on their plan in the immediate future. Conversely,
an example of suicidal ideation that involves intent with
no plan would be a patient who states that they are
going to kill themselves in the next week, but that they
do not know how they will do it yet. The most severe
form of suicidal ideation includes both a specific plan
and intent. That is, a patient has worked out the steps
that they will need to take in order to bring about their
death and intends to follow through on their plan in the
near future.
While the association between suicidal ideation and
suicidal behavior (including suicide and suicide
attempts) has been well established by correlational

studies, longitudinal studies have further demonstrated
that suicidal ideation is a major risk factor for subse-
quent suicidal behavior. Suicidal ideation consistently
predicts later suicide attempts in diverse samples of
adults and adolescents across many studies (Larzelere
et al., 1996; Kuo et al., 2001; Fergusson et al., 2005;
Reinherz et al., 2006; Wong et al., 2008; Britton &
Conner, 2010; Posner et al., 2011; Mundt et al., 2013;
O’Connor et al., 2013). Further, suicidal ideation has
also been found to prospectively predict death by sui-
cide in both inpatient and outpatient samples (Beck
et al., 1999; Brown et al., 2000; Joiner et al., 2003; Sani
et al., 2011; Wenzel et al., 2011; Mundt et al., 2013).
The measurement of suicidal ideation varies widely
across studies with some studies using a single question
(e.g., “Are you thinking about suicide?”) to other studies
using more comprehensive self-report questionnaires
or interviews to assess ideation. Although there are
numerous reliable and valid measures of suicidal idea-
tion, we have found only three measures with demon-
strated predictive validity for suicidal behavior: (1) Scale
for Suicide Ideation (SSI), (2) Columbia-Suicide Severity
Rating Scale (C-SSRS), and (3) Suicide Probability Scale
(SPS). The SSI is a 19-question structured interview that
assesses both current suicidal ideation (i.e., over the past
week) and suicidal ideation when it was at its worst in an
individual’s lifetime (Beck et al., 1997). It is the only
measure of suicide ideation that has demonstrated pre-
dictive validity for death by suicide in a sample of
psychiatric outpatients (Brown et al., 2000). The
C-SSRS is also an interview-based measure that assesses
current suicidal ideation as well as the worst point of
suicidal ideation in one’s life (Posner et al., 2011). This
predictive validity of the worst-point suicidal ideation
subscale has been established for suicide attempts in a
population of adolescents involved in outpatient treat-
ment (Posner et al., 2011). In a subsequent study, indi-
viduals who endorsed lifetime suicide ideation with
intent to act on the C-SSRS were five times more likely
to report suicidal behavior during follow-up than those
who did not (Mundt et al., 2013). Finally, the SPS is a
self-report inventory comprised of 36 items that meas-
ure suicidal ideation and related constructs such as
hopelessness (Cull & Gill, 1982). Like the C-SSRS, one
study supported the predictive validity of the SPS for
suicide attempts in adolescents (Larzelere et al., 1996).
When considering suicidal ideation in the context
of risk assessment, the literature suggests that it is
important to not only assess for current suicidal
ideation, but that past suicidal ideation at its worst
Downloaded from https://www.cambridge.org/core. University of Birmingham, on 18 Nov 2019 at 12:10:05, subject to the Cambridge Core terms of use, available at
https://www.cambridge.org/core/terms. https://doi.org/10.1017/CBO9781139519502.007
Chapter 5: High-risk cognitive states
point is also an important indicator for future risk. In
a landmark longitudinal study, death records of over
3500 outpatients seen consecutively over the course
of an almost 20-year period were collected in order to
determine those patients who later died by suicide
(Beck et al., 1999). This study revealed that scores on
the worst-point SSI at intake were much more
predictive of death by suicide than scores on the
current SSI as well as the Beck Hopelessness Scale.
A similar result was found for the worst-point
suicidal ideation severity score on the C-SSRS in the
prediction of future suicide attempts in outpatient
adolescents (Posner et al., 2011).
As discussed previously, the particular content
involved in an individual’s suicidal thinking may also
confer differential risk. Two of the most important
components of suicidal ideation to consider when con-
ducting a risk assessment are the determination of
whether an individual has a plan for suicide as well as
the intent to act on a plan to kill oneself. Patients with
suicide intent and/or plan have been found much more
likely to attempt suicide than those with no intent or
plan (Borges et al., 2006; Posner et al., 2011). Further,
those with high intent are much more likely to eventually
die by suicide than those without high intent (Suominen
et al., 2004; Stefansson et al., 2012). The presence of a
plan to kill oneself is also able to distinguish between
groups of individuals who have made recent suicide
attempts versus those who have not (Joiner et al., 1997;
Pettit et al., 2009). Similar to suicidal ideation in general,
the extent of a suicide plan at its worst point in one’s
lifetime is also particularly predictive of death by suicide
(Joiner et al., 2003).
It is important to note that individuals who think
about suicide do not necessarily wish for death all the
time (or alternately have no wish for life). Rather,
most individuals who experience suicidal thinking
vacillate between wishing to live and wishing to die,
in a conflict that has been coined an “internal debate”
(Kovacs & Beck, 1977; Harris et al., 2010). It is esti-
mated that around half of suicidal individuals expe-
rience this ambivalent state between wanting to live
and wanting to die and that patients who endorse this
conflict demonstrate lower levels of suicide intent
(Kovacs & Beck, 1977). Follow-up studies have sug-
gested that the magnitude of difference between the
wish to die versus the wish to live is an independent
risk factor for eventual suicide and that classifying
patients into typologies based on the degree of con-
flict (i.e., ambivalent, mostly wishes to live, mostly
43
 Section 1: Understanding Suicide
wishes to die) may relate to future suicide risk (Brown
et al., 2005; O’Connor et al., 2012).
Although research involving the assessment of sui-
cidal ideation on the risk of suicidal behavior has yielded
useful results, there are a number of research advances
that are recommended for further study. First, most of
the studies conducted have generally included samples
of adults or adolescents. Less is known about whether
current results are replicable in populations of older
adults. Given that older adults represent a particularly
high-risk group for suicide, research with suicidal elders
is especially warranted. Additionally, although greater
attention to operational definitions has been given in
recent years, a standard nomenclature for suicidal idea-
tion has yet to be adopted by researchers. The lack of
standard definitions can limit the ability to compare
results across studies and can cause confusion when
discussing these constructs. Thus, it is also recommen-
ded that standard operational definitions for types
of suicidal ideation are tested and agreed upon by con-
sensus in the field. Finally, while we have evidence to
suggest that suicidal ideation waxes and wanes over
time, our current methodology for measuring ideation
is unable to fully capture this phenomenon. Ecological
momentary assessment (EMA) is a novel method that
allows for assessing changes in suicidal ideation over
time and is a promising approach for collecting more
detailed information about how a suicidal crisis devel-
ops in real time (Shiffman & Stone, 1998). It is recom-
mended that future research incorporate EMA and
other novel assessment methods in order to gain more
accurate knowledge about the course of suicidal idea-
tion over time.
Attentional fixation
A concept that has received increasing attention over
recent years is the idea that not only do high-risk
individuals think about and desire suicide, but in fact
these individuals may have cognitive biases toward
suicide. For example, cognitive theory of suicide pos-
its that individuals at risk for suicide may have an
attentional bias toward suicide, such that they may
fixate on the idea of suicide to the exclusion of other
thoughts when experiencing negative emotions or a
crisis (Wenzel et al., 2009).
Researchers have investigated this phenomenon
using modified versions of the Stroop Test. This meas-
ure typically involves showing the subject a list of words
in different colors (e.g., blue, red, green, etc.) and
recording how quickly the subject can verbally identify
44
Downloaded from https://www.cambridge.org/core. University of Birmingham, on 18 Nov 2019 at 12:10:05, subject to the Cambridge Core terms of use, available at
https://www.cambridge.org/core/terms. https://doi.org/10.1017/CBO9781139519502.007
the color of the words (Stroop, 1935). The specific
content of the words may lead to longer response delays
because the subject diverts their attention to the specific
content of the word rather than its color. That is, specific
types of words may interfere with a subject’s ability to
perform the task, as evidenced by the subject taking
longer to identify the colors of the word types.
Indeed, individuals who attempted suicide had
longer responses to words with emotional content
than neutral words compared to psychiatric controls
(Williams & Broadbent, 1986). Additionally, suicide
attempters have been found to take longer to respond
to suicide-specific words versus other types of nega-
tive words compared to psychiatric patients who did
not attempt suicide as well as to control subjects
(Becker et al., 1999; Cha et al., 2010). Additionally,
performance on this task has been found to predict
the incidence of a repeat suicide attempt over a
6-month follow-up period above and beyond com-
mon clinical indicators of risk, such as severity of
suicide ideation, psychiatric diagnosis, and clinician
prediction (Cha et al., 2010).
While only a few studies have examined attentional
fixation as it relates to suicide, this is an area that
deserves increased attention. Additional prospective
studies of attentional fixation are warranted to deter-
mine if current results are replicable and generalizable.
This is another area in which novel assessment methods
such as EMA could be particularly helpful. Given that it
is theorized that attentional fixation is mood state-
dependent (Wenzel et al., 2009), it is especially impor-
tant to be able to examine attentional fixation in the
context of a suicidal crisis.
Hopelessness
Negative attitudes and pessimistic expectancies about
the future are also a significant risk factor for suicidal
behavior. A common misconception about the con-
struct of hopelessness is that it describes a feeling and
thus falls into the domain of emotion rather than
cognition. However, hopelessness is fundamentally a
belief (i.e., cognition) that involves making negative
predictions about the future.
Hopelessness is a unique construct in that it can
be both a state (i.e., something that can change)
and a trait (i.e., something that is relatively stable
and consistent over time). For example, some indi-
viduals may have stable, ongoing hopelessness that
occurs independently of negative affect or an episode
of mental illness. Some studies suggest that trait

hopelessness may be particularly important as they
have found that it predicts suicidal behavior beyond
state hopelessness (Young et al., 1996; Goldston et al.,
2006). Thus, it is important to not only assess for
levels of hopelessness when a patient is in distress,
but also to determine the degree of hopelessness
when the individual is not experiencing an extreme
mood state.
Hopeless cognitions are a significant predictor of
future death by suicide, such that individuals with
stronger beliefs that things are hopeless are at greater
risk for suicide (Beck et al., 1985, 1989, 1990; Clayton,
1993). In a landmark study on hopelessness with
psychiatric outpatients, death records were obtained
for nearly 2000 outpatients who had been seen over
the course of 6 years in an outpatient clinic (Beck
et al., 1990). In this study, hopelessness was assessed
using the Beck Hopelessness Scale (BHS) which is a
20-item self-report measure that asks an individual to
answer either true or false to a variety of statements
involving expectancies about the future (Beck &
Steer, 1988). The higher the score on the BHS, the
higher the level of hopelessness an individual is cur-
rently experiencing. The Beck et al. (1990) study
found that individuals who died by suicide had sig-
nificantly higher levels of hopelessness at intake than
those who did not.
Additional studies have also found evidence that
hopeless beliefs confer risk for suicidal behavior across
diverse samples of patients (Henriques et al., 2004;
Valtonen et al., 2006; Klonsky et al., 2012; Links et al.,
2012; O’Connor et al., 2013). Some studies have found
that hopelessness is a very robust predictor of suicide
attempts, conferring risk above and beyond highly pre-
dictive constructs such as a history of suicide attempts
and may be a particularly important factor for individ-
uals who have already made suicide attempts (Goldston
et al., 2001; Chandrasekaran & Gnanaselane, 2008;
Klonsky et al., 2012). Hopelessness has also been
studied as an explanatory construct and has been
found to mediate the relationship between depressive
symptoms and suicidal ideation and behaviors
(Minkoff et al., 1973; Beck et al., 1975, 1993; Dieserud
et al., 2001).
Future research on hopelessness should include
populations of older adults, who are not well-
represented in existing studies. Further research is
recommended that better measures and disentangles
state and trait hopelessness and their contribution to
Downloaded from https://www.cambridge.org/core. University of Birmingham, on 18 Nov 2019 at 12:10:05, subject to the Cambridge Core terms of use, available at
https://www.cambridge.org/core/terms. https://doi.org/10.1017/CBO9781139519502.007
Chapter 5: High-risk cognitive states
both near- and long-term risk in the prediction of
suicide and suicide attempts.
Problem solving deficits
A deficit in an individual’s ability (and perception of
their ability) to solve problems is also a cognitive risk
factor for suicidal behavior. Problem solving is a proc-
ess by which an individual generates adaptive solu-
tions to life problems (D’Zurilla & Chang, 1995).
Problem solving is theorized to consist of two primary
domains: problem orientation and problem solving
skills (D’Zurilla & Nezu, 1990). Problem orientation
is the set of responses (based on past experience) that
an individual brings to their problems. Problem solv-
ing skills usually include four tasks: defining the prob-
lem, generating alternative solutions, choosing a
solution, and finally implementing the solution and
evaluating its outcome.
Although problem solving is a construct that has
received much attention in the suicide literature, few
prospective studies have been done to examine the
effect of problem solving skills on suicide and suicide
attempts. Poor problem solving has been shown to
prospectively predict suicide attempts in two different
populations of adults (McAuliffe et al., 2002; Dieserud
et al., 2003). Most research studies in this area are cross-
sectional and involve comparing groups of individuals
(e.g., controls, individuals with suicidal ideation, indi-
viduals who made suicide attempts) in order to identify
the effects of problem solving on suicidal behavior.
Problem solving has been found to be associated with
suicidal ideation and attempts in a range of studies with
adults, older adults, and adolescents (Linehan et al.,
1987; McLeavey et al., 1987; Schotte & Clum, 1987;
Clum & Febbraro, 1994; Rudd et al., 1994; D’Zurilla
et al., 1998; Howat & Davidson, 2002; Pollock &
Williams, 2004; Williams et al., 2005; Gibbs et al.,
2009; Dour et al., 2011). Some studies further suggest
that individuals with an overgeneralized autobiograph-
ical memory are particularly prone to poor problem
solving (Pollock & Williams, 2001; Williams et al.,
2005). That is, individuals who tend to recall non-
specific general memories as opposed to specific events
tend to have greater difficulty solving problems, as it
may be more difficult for them to generalize from
specific past experiences.
Although there are a variety of instruments that
have been created to measure problem solving,
45
 Section 1: Understanding Suicide
the three most commonly used measures include:
(1) Problem Solving Inventory (PSI), (2) Means Ends
Problem Solving Task (MEPS), and (3) Social Problem
Solving Inventory-Revised (SPSI-R). The PSI is a
35-item self-report inventory designed to measure the
five components of problem solving described earlier
(Heppner & Petersen, 1982). The MEPS is a task that
presents a series of scenario vignettes to the subject and
the subject is asked to describe the best strategy to solve
the problem presented (Platt & Spivack, 1975). The
subject’s performance is then scored via the number
of effective problem solving steps generated, as well as
with an overall effectiveness score, and a score for how
specific the generated solution was. The SPSI-R, the
most widely used measure, is a 25-item self-report
inventory that contains five subscales: Positive
Problem Orientation, Negative Problem Orientation,
Rational Problem Solving, Impulsivity/Carelessness
Style, and Avoidance Style (D’Zurilla et al., 2002).
Positive problem orientation refers to viewing a prob-
lem as an opportunity rather than a threat (as in
Negative Problem Orientation). Rational problem solv-
ing measures the degree to which an individual pos-
sesses effective problem solving skills. The impulsivity
scale measures the degree to which an individual solves
problems impulsively and the avoidance scale measures
to what degree a person avoids active problem solving.
Given that much of the current research on prob-
lem solving is cross-sectional, further research on
problem solving should focus on examining this con-
struct using prospective methods in order to deter-
mine its unique contribution to the prediction of
suicidal behavior.
Perfectionism
Cognitions involving perfectionism have also been
studied for their role in suicide risk. Perfectionism
is often comprised of numerous unrealistic beliefs
that perfection of oneself or others is necessary for
success and that the lack of perfection will result in
failure. One theory of perfectionism purports to have
three components: (1) self-oriented perfectionism,
(2) socially prescribed perfectionism, and (3) other-
oriented perfectionism (Hewitt & Flett, 1991). Self-
oriented perfectionism involves strict self-evaluation
and the setting of very high personal standards.
Socially prescribed perfectionism is the belief that
one must attain the high standards that others have
46
Downloaded from https://www.cambridge.org/core. University of Birmingham, on 18 Nov 2019 at 12:10:05, subject to the Cambridge Core terms of use, available at
https://www.cambridge.org/core/terms. https://doi.org/10.1017/CBO9781139519502.007
for them. Other-oriented perfectionism involves set-
ting high standards for others and negative evaluative
beliefs of individuals who do not meet the standards.
Perfectionism is most commonly measured using the
Multidimensional Perfectionism Scale (MPS). The
MPS is a 45-item self-report scale that is designed to
measure the three components of perfectionism
(Hewitt & Flett, 1991).
Like problem solving deficits, limited prospective
research has been conducted to examine the effect of
perfectionism on suicide and suicide attempts. One
prospective study found that perfectionism at base-
line predicted suicidal ideation over a 6-month
follow-up period (Beevers & Miller, 2004). Much of
the data on the relationship between perfectionism
and suicide risk involves cross-sectional studies.
Perfectionism has been found to be associated with
suicidal ideation and intent (Hewitt et al., 1992, 1994,
1997; Hamilton & Schweitzer, 2000; Blankstein et al.,
2007; Flamenbaum & Holden, 2007). Further, the
literature suggests that self-oriented and socially pre-
scribed perfectionism may be particularly associated
with suicidal ideation (Hewitt et al., 1992, 1994, 1997;
Blankstein et al., 2007). Additionally, studies have
found that individuals who attempt suicide may evi-
dence higher levels of perfectionism than those who
have not attempted suicide (Hewitt et al., 1998;
Hunter & O’Connor, 2003). Although such research
shows promise for establishing a link between per-
fectionism and suicide risk, longitudinal studies of
perfectionism and suicidal behavior are warranted.
Homicidal ideation
Homicidal and suicidal thinking are related via their
shared content of aggression and violence, and there
is anecdotal evidence to suggest that, for a subset of
individuals, homicidal and suicidal behaviors are
associated with each other (e.g., murderers who kill
themselves after the act of homicide). However, there
is a paucity of research on the association between
homicidal ideation and suicidal behavior. To date, we
are aware of only one study on this topic that was
conducted in a sample of approximately 500 psychi-
atric outpatients, who were assessed for homicidal
and suicidal ideation and attempts (Asnis et al.,
1994). This study found that 91% of the patients
who had made past homicide attempts also made
suicide attempts in the past. Given this association,

it has been recommended that the assessment of
homicidal ideation should be included in any suicide
risk assessment (Wenzel et al., 2009). More research
in this area is greatly needed and encouraged as there
are no prospective studies examining the role of
homicidal ideation or attempts in suicide risk.
Additional recommendations for
future research
Future research should seek to address methodolog-
ical shortcomings that exist in the current literature.
For example, while adult and adolescent populations
are heavily represented, older adults and special
populations such as Veterans and Military Service
Members are understudied with regard to high-risk
cognitive states. There is also a pressing need for
longitudinal research, as cross-sectional studies are
limited in identifying causative pathways between
cognitive variables and suicidal behavior. More
research should be conducted to develop and test
theoretical models of how cognitive risk factors
might interact or otherwise work together to confer
risk for suicide. Additionally, further studies are
needed to examine how cognitive states are associated
with both near-term and long-term risk for suicide.
Many of the important studies that have found
predictive validity for cognitive states (e.g., suicidal
ideation and hopelessness) have focused on long
periods of follow-up over many years. Less is known
about short-term risk, especially over shorter dura-
tions of time (i.e., days and weeks). It is especially
important to gather more information about acute
short-term risk, as this is the most important time
period for clinicians assessing the safety of their
patients in clinical settings. Additionally, there is
limited information available about subtypes of
individuals and their corresponding risk levels with
regard to cognitive states. For example, do fluctua-
tions of cognitive states, such as suicidal ideation or
hopelessness, confer more or less risk than chroni-
cally high levels of such states?
An important consideration for future research is
the ethical obligation to maintain patient safety over
the course of a longitudinal research study. Learning
that a patient is at risk for suicide may necessitate
intervention to reduce the risk of suicide. This is par-
ticularly important to consider for studies using EMA
during which patients may be responding to assess-
ments at several points during a day or week. For these
Downloaded from https://www.cambridge.org/core. University of Birmingham, on 18 Nov 2019 at 12:10:05, subject to the Cambridge Core terms of use, available at
https://www.cambridge.org/core/terms. https://doi.org/10.1017/CBO9781139519502.007
Chapter 5: High-risk cognitive states
studies, it is imperative that they include a plan for
monitoring patient responses and intervening as clin-
ically appropriate.
Additionally, there are many cognitive risk factors
that are emerging in the literature that warrant further
prospective study to assess their association with future
suicidal behavior. For example, the cognitive factors in
Joiner’s Interpersonal-Psychological Theory of suicide
have been gaining increasing research attention and
should be further studied. These factors are perceived
burdensomeness, the belief that one is a burden to
others, and thwarted belongingness, the belief that one
does not have meaningful relationships with other peo-
ple (Van Orden et al., 2005). Additionally, Shneidman’s
concept of psychache, or psychological pain that is
believed to be intolerable or unbearable, is another
understudied cognitive state (Shneidman, 1993).
Similarly, helplessness (i.e., the belief that one cannot
escape negative situations), which has been extensively
studied for its role in depression (Seligman, 1975)
should be further examined for its potential role in
suicide risk.
In addition to these cognitive states, there are also
other cognitive processes that should be further exam-
ined for their role in suicide. Cognitive rigidity, or an
inflexible style of perceiving and interacting with the
world, might be particularly applicable to suicide and
could perhaps be a potential underlying cognitive
process for problem solving deficits (Patsiokas et al.,
1979). Memory is also an important cognitive process
that may have important effects on cognitive states and
therefore the risk for suicide and should be more
explicitly studied. Similarly, implicit associations
have recently gained attention in the literature and
more research should be done to elucidate their role
in suicide risk (Nock et al., 2010). A final important
area for further research is to begin to identify how
cognitive states are related to potential biomarkers for
suicide in order to elucidate the biological underpin-
nings that characterize suicide risk.
In conclusion, the suicide literature contains
important findings on high-risk cognitive states for
suicide such as identifying measures of suicidal idea-
tion and hopelessness that have demonstrated pre-
dictive validity for suicide. This chapter also describes
other cognitive states and cognitive processes, such as
perfectionism, problem solving deficits, homicidal
ideation, and attentional fixation, which clearly war-
rant further research using prospective research
designs for understanding suicide risk. Other
47
 Section 1: Understanding Suicide
cognitive processes, such as cognitive rigidity, mem-
ory, psychological pain and implicit associations for
suicide, also show promise for conferring risk.
References
Asnis, G. M., Kaplan, M. L., van Praag, H. M., &
Sanderson, W. C. (1994). Homicidal behaviors among
psychiatric outpatients. Hospital & Community
Psychiatry, 45(2), 127–132.
Beck, A. T., & Steer, R. A. (1988). Manual for the Beck
Hopelessness Scale. San Antonio, TX: Psychological
Corporation.
Beck, A. T., Kovacs, M., & Weissman, A. (1975).
Hopelessness and suicidal behavior: An overview. JAMA,
234(11), 1146–1149.
Beck, A. T., Steer, R. A., Kovacs, M., & Garrison, B. (1985).
Hopelessness and eventual suicide: A 10-year prospective
study of patients hospitalized with suicidal ideation. The
American Journal of Psychiatry, 142(5), 559–563.
Beck, A. T., Brown, G., & Steer, R. A. (1989). Prediction of
eventual suicide in psychiatric inpatients by clinical
ratings of hopelessness. Journal of Consulting and Clinical
Psychology, 57(2), 309–310.
Beck, A. T., Brown, G., Berchick, R. J., Stewart, B. L., &
Steer, R. A. (1990). Relationship between hopelessness
and ultimate suicide: A replication with psychiatric
outpatients. The American Journal of Psychiatry, 147(2),
190–195.
Beck, A. T., Steer, R. A., Beck, J. S., & Newman, C. F. (1993).
Hopelessness, depression, suicidal ideation, and clinical
diagnosis of depression. Suicide and Life-Threatening
Behavior, 23(2), 139–145.
Beck, A. T., Brown, G. K., & Steer, R. A. (1997).
Psychometric characteristics of the scale for suicide
ideation with psychiatric outpatients. Behaviour Research
and Therapy, 35(11), 1039–1046.
Beck, A. T., Brown, G. K., Steer, R. A., Dahlsgaard, K. K., &
Grisham, J. R. (1999). Suicide ideation at its worst point:
A predictor of eventual suicide in psychiatric outpatients.
Suicide and Life-Threatening Behavior, 29(1), 1–9.
Becker, E. S., Strohbach, D., & Rinck, M. (1999). A specific
attentional bias in suicide attempters. Journal of Nervous
and Mental Disease, 187(12), 730–735.
Beevers, C. G., & Miller, I. W. (2004). Perfectionism,
cognitive bias, and hopelessness as prospective predictors
of suicidal ideation. Suicide and Life-Threatening
Behavior, 34(2), 126–137.
Blankstein, K. R., Lumley, C. H., & Crawford, A. (2007).
Perfectionism, hopelessness, and suicide ideation:
Revisions to diathesis-stress and specific vulnerability
models. Journal of Rational-Emotive & Cognitive-
Behavior Therapy, 25(4), 279–319.
48
Downloaded from https://www.cambridge.org/core. University of Birmingham, on 18 Nov 2019 at 12:10:05, subject to the Cambridge Core terms of use, available at
https://www.cambridge.org/core/terms. https://doi.org/10.1017/CBO9781139519502.007
Borges, G., Angst, J., Nock, M. K., et al. (2006). A risk index
for 12-month suicide attempts in the National
Comorbidity Survey Replication(NCS-R). Psychological
Medicine, 36(12), 1747–1757.
Borges, G., Nock, M. K., Haro Abad, J. M., et al. (2010).
Twelve-month prevalence of and risk factors for suicide
attempts in the World Health Organization World
Mental Health Surveys. Journal of Clinical Psychiatry, 71
(12), 1617–1628.
Britton, P. C., & Conner, K. R. (2010). Suicide attempts
within 12 months of treatment for substance use
disorders. Suicide and Life-Threatening Behavior, 40(1),
14–21.
Brown, G. K., Beck, A. T., Steer, R. A., & Grisham, J. R.
(2000). Risk factors for suicide in psychiatric outpatients:
a 20-year prospective study. Journal of Consulting and
Clinical Psychology, 68(3), 371–377.
Brown, G. K., Steer, R. A., Henriques, G. R., & Beck, A. T.
(2005). The internal struggle between the wish to die and
the wish to live: A risk factor for suicide. The American
Journal of Psychiatry, 162(10), 1977–1979.
Cha, C. B., Najmi, S., Park, J. M., Finn, C. T., & Nock, M. K.
(2010). Attentional bias toward suicide-related stimuli
predicts suicidal behavior. Journal of Abnormal
Psychology, 119(3), 616–622.
Chandrasekaran, R., & Gnanaselane, J. (2008). Predictors of
repeat suicidal attempts after first-ever attempt: A two-
year follow-up study. Hong Kong Journal of Psychiatry, 18
(4), 131–135.
Clayton, P. I. (1993). Suicide in panic disorder and depression.
Current Therapeutic Research, 54(6), 825–831.
Clum, G. A., & Febbraro, G. A. R. (1994). Stress, social
support, and problem solving appraisal/skills:
Prediction of suicide severity within a college sample.
Journal of Psychopathology and Behavioral Assessment,
16(1), 69–83.
Crosby, A., Ortega, L., & Melanson, C. (2011). Self-directed
Violence Surveillance: Uniform Definitions and
Recommended Data Elements, Version 1.0. Atlanta, GA:
Centers for Disease Control and Prevention, National
Center for Injury Prevention and Control.
Cull, J. G., & Gill, W. (1982). Suicide Probablity Scale. Los
Angeles, CA: Western Psychological Services.
D’Zurilla, T. J., & Chang, E. C. (1995). The relations between
social problem solving and coping. Cognitive Therapy and
Research, 19(5), 547–562.
D’Zurilla, T. J., & Nezu, A. M. (1990). Development and
preliminary evaluation of the Social Problem Solving
Inventory. Psychological Assessment: A Journal of
Consulting and Clinical Psychology, 2(2), 156–163.
D’Zurilla, T. J., Chang, E. C., Nottingham, E. J., &
Faccini, L. (1998). Social problem solving deficits and
hopelessness, depression, and suicidal risk in college

students and psychiatric inpatients. Journal of Clinical
Psychology, 54(8), 1091–1107.
D’Zurilla, T. J., Nezu, A. M., & Maydeu-Olivares, A. (2002).
Manual for the Social Problem Solving Inventory-Revised.
North Tonawanda, NY: Multi-Health Systems.
Dieserud, G., Røysamb, E., Ekeberg, Ø., & Kraft, P. (2001).
Toward an integrative model of suicide attempt: A
cognitive psychological approach. Suicide and Life-
Threatening Behavior, 31(2), 153–168.
Dieserud, G., Røysamb, E., Braverman, M. T.,
Dalgard, O. S., & Ekeberg, Ø. (2003). Predicating
repetition of suicide attempt: A prospective study of 50
suicide attempters. Archives of Suicide Research, 7(1), 1–15.
Dour, H. J., Cha, C. B., & Nock, M. K. (2011). Evidence for an
emotion-cognition interaction in the statistical prediction
of suicide attempts. Behaviour Research and Therapy,
49(4), 294–298.
Fergusson, D. M., Horwood, L. J., Ridder, E. M., &
Beautrais, A. L. (2005). Suicidal behaviour in adolescence
and subsequent mental health outcomes in young
adulthood. Psychological Medicine, 35(7), 983–993.
Flamenbaum, R., & Holden, R. R. (2007). Psychache as a
mediator in the relationship between perfectionism
and suicidality. Journal of Counseling Psychology,
54(1), 51–61.
Gibbs, L. M., Dombrovski, A. Y., Morse, J., et al. (2009).
When the solution is part of the problem: Problem
solving in elderly suicide attempters. International
Journal of Geriatric Psychiatry, 24(12), 1396–1404.
Goldston, D. B., Daniel, S. S., Reboussin, B. A., et al. (2001).
Cognitive risk factors and suicide attempts among
formerly hospitalized adolescents: A prospective
naturalistic study. Journal of the American Academy of
Child & Adolescent Psychiatry, 40(1), 91–99.
Goldston, D. B., Reboussin, B. A., & Daniel, S. S. (2006).
Predictors of suicide attempts: State and trait
components. Journal of Abnormal Psychology, 115(4),
842–849.
Hamilton, T. K., & Schweitzer, R. D. (2000). The cost of
being perfect: Perfectionism and suicide ideation in
university students. Australian and New Zealand Journal
of Psychiatry, 34(5), 829–835.
Harris, K. M., McLean, J. P., Sheffield, J., & Jobes, D. (2010).
The internal suicide debate hypothesis: Exploring the life
versus death struggle. Suicide and Life-Threatening
Behavior, 40(2), 181–192.
Henriques, G. R., Brown, G. K., Berk, M. S., & Beck, A. T.
(2004). Marked increases in psychopathology found in a
30-year cohort comparison of suicide attempters.
Psychological Medicine, 34(5), 833–841.
Heppner, P. P., & Petersen, C. H. (1982). The development
and implications of a personal problem solving
inventory. Journal of Counseling Psychology, 29(1), 66–75.
Downloaded from https://www.cambridge.org/core. University of Birmingham, on 18 Nov 2019 at 12:10:05, subject to the Cambridge Core terms of use, available at
https://www.cambridge.org/core/terms. https://doi.org/10.1017/CBO9781139519502.007
Chapter 5: High-risk cognitive states
Hewitt, P. L., & Flett, G. L. (1991). Perfectionism in the self
and social contexts: Conceptualization, assessment, and
association with psychopathology. Journal of Personality
and Social Psychology, 60(3), 456–470.
Hewitt, P. L., Flett, G. L., & Turnbull-Donovan, W. (1992).
Perfectionism and suicide potential. British Journal of
Clinical Psychology, 31(2), 181–190.
Hewitt, P. L., Flett, G. L., & Weber, C. (1994). Dimensions of
perfectionism and suicide ideation. Cognitive Therapy
and Research, 18(5), 439–460.
Hewitt, P. L., Newton, J., Flett, G. L., & Callander, L. (1997).
Perfectionism and suicide ideation in adolescent
psychiatric patients. Journal of Abnormal Child
Psychology, 25(2), 95–101.
Hewitt, P. L., Norton, R., Flett, G. L., Callander, L., &
Cowan, T. (1998). Dimensions of perfectionism,
hopelessness, and attempted suicide in a sample of
alcoholics. Suicide and Life-Threatening Behavior,
28(4), 395–406.
Howat, S., & Davidson, K. (2002). Parasuicidal behaviour
and interpersonal problem solving performance in older
adults. British Journal of Clinical Psychology, 41(4),
375–386.
Hunter, E. C., & O’Connor, R. C. (2003). Hopelessness and
future thinking in parasuicide: The role of perfectionism.
British Journal of Clinical Psychology, 42(4), 355–365.
Joiner, T. E., Jr., Rudd, M. D., & Rajab, M. H. (1997). The
Modified Scale for Suicidal Ideation: Factors of suicidality
and their relation to clinical and diagnostic variables.
Journal of Abnormal Psychology, 106(2), 260–265.
Joiner, T. E., Jr., Steer, R. A., Brown, G., et al. (2003). Worst-
point suicidal plans: A dimension of suicidality predictive
of past suicide attempts and eventual death by suicide.
Behaviour Research and Therapy, 41(12), 1469–1480.
Kessler, R. C., Borges, G., & Walters, E. E. (1999). Prevalence
of and risk factors for lifetime suicide attempts in the
National Comorbidity Survey. Archives of General
Psychiatry, 56(7), 617–626.
Klonsky, E. D., Kotov, R., Bakst, S., Rabinowitz, J., &
Bromet, E. J. (2012). Hopelessness as a predictor of
attempted suicide among first admission patients with
psychosis: A 10-year cohort study. Suicide and Life-
Threatening Behavior, 42(1), 1–10.
Kovacs, M., & Beck, A. T. (1977). The wish to die and the
wish to live in attempted suicides. Journal of Clinical
Psychology, 33(2), 361–365.
Kuo, W.-H., Gallo, J. J., & Tien, A. Y. (2001). Incidence of
suicide ideation and attempts in adults: The 13-year
follow-up of a community sample in Baltimore,
Maryland. Psychological Medicine, 31(7), 1181–1191.
Larzelere, R. E., Smith, G. L., Batenhorst, L. M., & Kelly, D. B.
(1996). Predictive validity of the suicide probability scale
among adolescents in group home treatment. Journal of
49
 Section 1: Understanding Suicide
the American Academy of Child & Adolescent Psychiatry,
35(2), 166–172; discussion 172–174.
Linehan, M. M., Camper, P., Chiles, J. A., Strosahl, K., &
Shearin, E. (1987). Interpersonal problem solving
and parasuicide. Cognitive Therapy and Research,
11(1), 1–12.
Links, P., Nisenbaum, R., Ambreen, M., et al. (2012).
Prospective study of risk factors for increased suicide
ideation and behavior following recent discharge. General
Hospital Psychiatry, 34(1), 88–97.
McAuliffe, C., Keeley, H. S., & Corcoran, P. (2002). Problem
solving and repetition of parasuicide. Behavioural and
Cognitive Psychotherapy, 30(4), 385–397.
McLeavey, B. C., Daly, R. J., Murray, C. M., O’Riordan, J., &
Taylor, M. (1987). Interpersonal problem solving deficits
in self-poisoning patients. Suicide and Life-Threatening
Behavior, 17(1), 33–49.
Minkoff, K., Bergman, E., Beck, A. T., & Beck, R. (1973).
Hopelessness, depression, and attempted suicide. The
American Journal of Psychiatry, 130(4), 455–459.
Mundt, J. C., Greist, J. H., Jefferson, J. W., et al. (2013).
Prediction of suicidal behavior in clinical research by
lifetime suicidal ideation and behavior ascertained by the
Electronic Columbia-Suicide Severity Rating Scale.
Journal of Clinical Psychiatry, 74(9), 887–893.
Nock, M. K., Park, J. M., Finn, C. T., et al. (2010). Measuring
the suicidal mind: Implicit cognition predicts suicidal
behavior. Psychological Science, 21(4), 511–517.
O’Connor, R. C., Smyth, R., Ferguson, E., Ryan, C., &
Williams, J. M. G. (2013). Psychological Processes and
Repeat Suicidal Behavior: A Four-Year Prospective
Study. Journal of Consulting and Clinical Psychology, 81
(6), 1137–1143.
O’Connor, S. S., Jobes, D. A., Yeargin, M. K., et al. (2012). A
cross-sectional investigation of the suicidal spectrum:
Typologies of suicidality based on ambivalence about
living and dying. Comprehensive Psychiatry, 53(5),
461–467.
Patsiokas, A. T., Clum, G. A., & Luscomb, R. L. (1979).
Cognitive characteristics of suicide attempters. Journal of
Consulting and Clinical Psychology, 47(3), 478–484.
Pettit, J. W., Garza, M. J., Grover, K. E., et al. (2009). Factor
structure and psychometric properties of the Modified
Scale for Suicidal Ideation among suicidal youth.
Depression and Anxiety, 26(8), 769–774.
Platt, J. J., & Spivack, G. (1975). Manual for the Means-End
Problems Solving (MEPS): A Measure of Interpersonal
Problem Solving Skill. Philadelphia, PA: Hahnemann
Medical College and Hospital.
Pollock, L. R., & Williams, J. M. G. (2001). Effective problem
solving in suicide attempters depends on specific
autobiographical recall. Suicide and Life-Threatening
Behavior, 31(4), 386–396.
50
Downloaded from https://www.cambridge.org/core. University of Birmingham, on 18 Nov 2019 at 12:10:05, subject to the Cambridge Core terms of use, available at
https://www.cambridge.org/core/terms. https://doi.org/10.1017/CBO9781139519502.007
Pollock, L. R., & Williams, J. M. G. (2004). Problem solving
in suicide attempters. Psychological Medicine, 34(1),
163–167.
Posner, K., Brown, G. K., Stanley, B., et al. (2011). The
Columbia-Suicide Severity Rating Scale: Initial validity
and internal consistency findings from three multisite
studies with adolescents and adults. The American
Journal of Psychiatry, 168(12), 1266–1277.
Reinherz, H. Z., Tanner, J. L., Berger, S. R.,
Beardslee, W. R., & Fitzmaurice, G. M. (2006). Adolescent
suicidal ideation as predictive of psychopathology,
suicidal behavior, and compromised functioning at age
30. The American Journal of Psychiatry, 163(7),
1226–1232.
Rudd, M. D., Rajab, M. H., & Dahm, P. F. (1994). Problem
solving appraisal in suicide ideators and attempters.
American Journal of Orthopsychiatry, 64(1), 136–149.
Sani, G., Tondo, L., Koukopoulos, A., et al. (2011).
Suicide in a large population of former psychiatric
inpatients. Psychiatry and Clinical Neurosciences,
65(3), 286–295.
Schotte, D. E., & Clum, G. A. (1987). Problem solving skills
in suicidal psychiatric patients. Journal of Consulting and
Clinical Psychology, 55(1), 49–54.
Seligman, M. E. P. (1975). Helplessness: On Depression,
Development, and Death: New York, NY: W H Freeman/
Times Books/ Henry Holt & Co.
Shiffman, S. M., & Stone, A. A. (1998). Ecological
momentary assessment: A new tool for behavioral
medicine research. In Technology and Methods in
Behavioral Medicine (pp. 117–131). Mahwah, NJ:
Lawrence Erlbaum Associates.
Shneidman, E. S. (1993). Suicide as Psychache: A Clinical
Approach to Self-Destructive Behavior. Lanham, MD.
Jason Aronson.
Stefansson, J., Nordström, P., & Jokinen, J. (2012). Suicide
Intent Scale in the prediction of suicide. Journal of
Affective Disorders, 136(1–2), 167–171.
Stroop, J. R. (1935). Studies of interference in serial verbal
reactions. Journal of Experimental Psychology, 18(6),
643–662.
Suominen, K., Isometsä, E., Ostamo, A., & Lönnqvist, J.
(2004). Level of suicidal intent predicts overall mortality
and suicide after attempted suicide: A 12-year follow-up
study. BMC Psychiatry, 4, 11.
Valtonen, H. M., Suominen, K., Mantere, O., et al. (2006).
Prospective study of risk factors for attempted suicide
among patients with bipolar disorder. Bipolar Disorders,
8(5 pt 2), 576–585.
Van Orden, K. A., Merrill, K. A., & Joiner, T. E., Jr. (2005).
Interpersonal-psychological precursors to suicidal
behavior: A theory of attempted and completed suicide.
Current Psychiatry Reviews, 1(2), 187–196.

Wenzel, A., Brown, G. K., & Beck, A. T. (2009). Cognitive
Therapy for Suicidal Patients: Scientific and Clinical
Applications: Washington, DC: American Psychological
Association.
Wenzel, A., Berchick, E. R., Tenhave, T., et al. (2011).
Predictors of suicide relative to other deaths in patients with
suicide attempts and suicide ideation: A 30-year prospective
study. Journal of Affective Disorders, 132(3), 375–382.
Williams, J. M., & Broadbent, K. (1986). Distraction by
emotional stimuli: Use of a Stroop task with suicide
attempters. British Journal of Clinical Psychology, 25(2),
101–110.
Downloaded from https://www.cambridge.org/core. University of Birmingham, on 18 Nov 2019 at 12:10:05, subject to the Cambridge Core terms of use, available at
https://www.cambridge.org/core/terms. https://doi.org/10.1017/CBO9781139519502.007
Chapter 5: High-risk cognitive states
Williams, J. M., Barnhofer, T., Crane, C., & Beck, A. T.
(2005). Problem solving deteriorates following mood
challenge in formerly depressed patients with a history
of suicidal ideation. Journal of Abnormal Psychology,
114(3), 421–431.
Wong, J. P. S., Stewart, S. M., Claassen, C., et al. (2008).
Repeat suicide attempts in Hong Kong community
adolescents. Social Science & Medicine, 66(2), 232–241.
Young, M. A., Fogg, L. F., Scheftner, W., et al. (1996). Stable
trait components of hopelessness: Baseline and sensitivity
to depression. Journal of Abnormal Psychology, 105(2),
155–165.
51