Archives of Suicide Research, 18:295–312, 2014

Copyright # International Academy for Suicide Research

ISSN: 1381-1118 print=1543-6136 online
DOI: 10.1080/13811118.2013.824825

Psychological Models of
Suicide
Shira Barzilay and Alan Apter

Suicidal behavior is highly complex and multifaceted. Consequent to the pioneering

work of Durkheim and Freud, theoreticians have attempted to explain the biological,
social, and psychological nature of suicide. The present work presents an overview and
critical discussion of the most influential theoretical models of the psychological
mechanisms underlying the development of suicidal behavior. All have been tested
to varying degrees and have important implications for the development of therapeutic
and preventive interventions. Broader and more in-depth approaches are still needed
to further our understanding of suicidal phenomena.

Keywords NSSI, self-destructive behavior, self-harm, self-mutilation, suicide

There is nothing more practical than a good contextual=background factors interact

theory
K. Lewin (1951, p. 169)
INTRODUCTION
Despite the substantial research on suicidal
behavior and its correlates, there have been
few attempts to fit the established data into
a coherent overarching theory. Suicidal
behaviors are not isolated acts but a spec-
trum of activities related to a diversity of
risk factors. Thus, to form a useful theory
of suicide, researchers need to go beyond
associations of suicide behaviors and focus
on causal mechanisms (Brent, 2011; Nock,
2009). As noted by Prinstein (2008), a
sound theoretical model of suicide has to
meet several criteria: It must be consistent
with the empirically documented risk fac-
tors and be able to account for them; it
must comprehensively address the interplay
between intra-individual dynamic systems
and inter-individual risk factors; and it must
offer insight into the processes whereby
with proximal triggers to predict the emerg-
ence of suicidal ideation and behavior.
The aim of the present work was to
review and critically discuss the predominant
psychological theories of suicidal phenom-
ena which we believe have made important
contributions to the field. We focused
mainly on contemporary models based on
empirical research that address the psycho-
logical mechanisms underlying the develop-
ment of suicidal behavior. All have been
tested and found to have varying degrees
of empirical support (see Table 1). Because
the classical psychodynamic theories have
received substantial attention over the years,
they are summarized only briefly.
Classical Psychodynamic Theories
Freud’s first observations on
self-destruction led to psychoanalytic the-
ories and studies that have influenced the
exploration of suicide. In his seminal work,
Beyond the Pleasure Principle, Freud (1920)
conceptualized the internal forces that pro-
mote self-destruction. He postulated that

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 Psychological Models of Suicide

TABLE 1. Empirical Psychological Models of Suicidal Behavior

Author Main assumptions

Baumeister (1990) Unbearable state of distorted self-awareness causes cognitive

deconstruction and a search for a means to escape.
Beck, Brown, Berchick et al. (1990) Suicide schema of biases in attention, information processing, and
memory impairs the individual’s ability to recall reasons for living or
being hopeful about life.
Brent & Mann (2006) Familial transmission of the impulsive-aggressive trait places individuals
at higher risk of suicidal behavior.
Joiner (2005) Feelings of non-belongingness and burdensomeness lead to a desire for
death. The realization of this desire is determined by one’s acquired
capability for self-harm.
O’Connor (2011) Suicidal behavior results from the interplay among background factors,
motivational factors, and volitional (i.e., behavioral enactment)
factors.
Plutchik, van Praag, & Conte (1989) Certain risk factors determine the level of impulsive aggression that
leads to violent act, while the presence of other factors determines if
aggression is directed inward or outward.
Rudd (2006) Cognitive, behavioral, physiological, and affective characteristics of the
suicide mode predict vulnerability to triggers and the severity and
duration of suicidal crises.
Schotte & Clum (1987) A deficit in interpersonal problem-solving increases the risk of suicidal
behavior as a reaction to stress.
Shneidman (1993) Unmet psychological needs cause torturing mental pain that leads to
suicide as the only option.
Williams (1997) Suicidal ideation develops from feelings of entrapment due to defeat in
stressful situations.

the life and death drives were opposing
basic instincts. The life drive was directed
at reducing the tension associated with sur-
vival needs; the death drive was directed at
eliminating the tension of life itself. Freud
argued that the universal goal of all organ-
isms is to return to the quiescence of the
inorganic world and that repetition compul-
sion forms the basis of all self-defeating
behaviors. He believed that the energy to kill
oneself derived from an earlier repressed
desire to destroy another. Suicide repre-
sented an internalization of this object and
a turning of the external death wish inward,
against a fragment of one’s own ego.
Elaborating on Freud’s death instinct,
Menninger (1938) claimed that every sui-
cide is an inverted homicide, or ‘‘murder
in the 180th degree.’’ He conceptualized a
suicidal triad consisting of the wish to kill
(murder), the wish to be killed (guilt), and
the wish to die (depression). The wish to
kill is originally oriented to an external
object and later introjected into the ego,
leading to feelings of guilt for wishing
loved ones dead. As one’s ego is destroyed
by self-hate and guilt, a depressed, hopeless
wish to die evolves, and the wish to
be killed as punishment for thoughts of
destroying others. Menninger (1938) linked

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suicide and self-harm to castrating or
mutilating fantasies directed toward one’s
parents and siblings.
Klein (1935, 1946) further emphasized
the role of the death instinct, asserting that
primitive envy in early life represents a
severe form of innate aggression. In the
view of Klein’s theory, suicide is caused
by unbearable guilt over aggressive fanta-
sies towards internalized objects. The guilt
causes feelings of badness and destructive-
ness. Suicide is therefore an attempt to pre-
vent one’s own destructiveness. This
psychodynamic theory was the first to
emphasize the role of object-relations in
the suicidal process.
Early psychoanalytical approaches to
understanding the suicidal mind were
intuitively inclusive and meaningful. They
created a historical change of how suicide
was perceived, from moral, legal, philo-
sophical, or spiritual problem to a clinical
concern (Ellis, 2001). Their innovative view
of suicide as a result of psychological dis-
tress or disorder set the ground for all
further investigations. Some ideas of these
‘‘grand theories’’ have remained influential.
For example, the primary role of impulsive-
aggressive in empirical psychological mod-
els of suicide could be seen as rooted in
the Freud and Menninger perspectives.
Furthermore, the interpersonal models of
suicide seem to share common elements
with object relations theories linking suici-
dal wishes to feeling of guilt.
There has been some effort to show
empirical evidence for psychodynamic for-
mulations of suicide (Fowler, Hilsenroth,
Groat et al., 2012; Maltsberger, 2004).
Orbach (1996, 2003) demonstrated the
relationship between early negative attach-
ment and development of suicidal behavior
as a result of negative attitudes toward the
body, which was conceptualized as ‘‘the
suicidal body.’’ Other studies supported
the conceptualization of suicide as
aggression turned inward. (Apter, Plutchik,
& van Praag, 1993; Maiuro, O’Sullivan, &
ARCHIVES OF SUICIDE RESEARCH
S. Barzilay and A. Apter
Vitanliano, 1989; Rustein & Goldberg,
1973; Tatman, Greene, & Karr, 1993).
However in general the major short-
coming of psychodynamic theories is that
they are mostly unsuitable for empirical
testing. Other criticisms of psychodynamic
approaches center on the notion of self-
destructiveness as an integral biological
need of the human personality. Baumeister
and Scher (1988) studied the concept of
primary self-destruction, defined as the
intention of harming or defeating the self
that may reflect a desire to be punished
or a desire to harm a disliked self. They
found no empirical evidence for primary
self-destruction in humans. This suggests
that only distorted psychological conditions
could result in suicide.
Psychological Pain Theories
Shneidman’s Theory of Psychache. Shneidman
(1993) defined ten common factors (‘‘com-
munalities’’) of suicide: seeking a solution,
cessation of consciousness, intolerable
psychological pain, frustrated psychological
needs, hopelessness and helplessness,
ambivalence towards life and death, con-
striction of viable alternatives, flight from
life itself, communication of intent, and
dysfunctional lifelong coping patterns. He
suggested that suicide is caused by psychache
(Shneidman, 1993, p. 51), an intense and
intolerable emotional pain that is different
from depression and hopelessness. The
tortured individual seeks relief for his=her
pain until there is no solution but death.
He postulated two types of needs: primary
or biological and secondary or psychologi-
cal. The psychological needs that are essen-
tial for life include, among others, love and
belonging, sense of control, positive self-
image, and meaningful relationships. It is
the frustration of these needs by failures,
rejections, and loss that leads to the devel-
opment of psychache. The view of the sui-
cidal act as being instrumental in fulfilling a
297

specific need is rooted in psychodynamic
formulations. In psychodynamic theories
self-destruction may also be intended to
achieve a goal or fulfill a need such as
joining a loved one (in fantasy), enhancing
self-worth, or gaining love.
Shneidman’s concepts form the basis
of many contemporary suicide models,
and they have directly or indirectly shaped
many of the terms used in the field (Jobes
& Nelson, 2006). Shneidman’s conceptuali-
zation of suicide as a problem-solving
behavior (Shneidman, 1993) influenced
other psychological theories of suicide,
such as the escape theory (Baumeister,
1990) and the cry of pain model (Williams,
1997). Initial support for psychache as a
factor in suicide is strong. Psychache has
been shown to be a significant predictor
of suicide ideation and attempts (Flynn &
Holden, 2007; Holden, Mehta, Cunningham
et al., 2001; Mills, Green, & Reddon, 2005;
Patterson & Holden, 2012; Pereira, Kroner,
Holden et al., 2010; Troister & Holden,
2010a; Troister & Holden, 2010b). Research
has also supported Shneidman’s assertion
that the relationship of other factors with
suicide is mediated by psychache, and that
psychache and suicide ideation co-vary over
time (DeLisle & Holden, 2009; Troister &
Holden, 2012).
However, research supporting Shneid-
man’s theory is limited. First, a generally
accepted understanding and clear definition
of what is constituted by psychological pain
does not exist. It is not clear what cogni-
tions and emotions characterize psychache.
Second, there are extremely strong correla-
tions among psychache, depression, and
hopelessness (approximately r ¼ .80 in
Troister & Holden, 2012). Therefore it
can be argued that these constructs are
not independent. Third, to further establish
psychache as a causal factor of suicidal
outcomes, there is a need for research with
larger sample sizes, high-risk suicidal groups
and longitudinal designs. Finally, from
the theoretical perspective, the claim that
298 VOLUME 18  NUMBER 4  2014
Psychological Models of Suicide
psychache is sufficient was not consistently
supported. The majority of people who dis-
play psychological pain do not experience
suicidal ideation or exhibit suicidal beha-
vior. Therefore there are questions remain-
ing about how psychache interacts with
other risk factors to bring about suicide
and what pathways lead from psychache
to suicide.
Suicide as an Escape from the Self
Baumeister (1990) argued that the
most common motive reported by people
for engaging in suicidal behavior is to
escape from an aversive situation and to
obtain respite from an unbearable state of
mind. He described six steps leading to
suicidality. First, there is a discrepancy
between expected standards and perceived
reality. Too-high expectations or setbacks
frustrate goals and lead to personal failure.
Second, the individual interprets the failure
as a function of his own characteristics,
qualities, or skills, leading to self-blame.
Third, an aversive state of distorted
self-awareness leads to unforgiving com-
parison of the self with unachieved stan-
dards. Fourth, this self-awareness evokes
painful negative emotions. Fifth, the indi-
vidual attempts to escape into a relatively
numb state of cognitive deconstruction,
characterized by his=her focusing on con-
crete sensations and movements and tar-
geting only immediate goals. Finally
cognitive deconstruction results in reduced
behavioral inhibition with emergence of
suicide and other life-threatening beha-
viors. This step separates suicidal ideation
from actual suicide, with the behavioral dis-
inhibition overcoming the fear of causing
oneself pain through death.
Baumeister’s theory largely rejects the
concept that suicide is a sort of self-
execution and postulates that the appeal of
suicide is loss of consciousness and cessation
of psychological pain. Another unique

assumption is that negative suicidal
emotions are experienced as an acute state
rather than a prolonged one. Baumeister
draws upon Baechler’s early model of
suicide-as-escape (Baechler, 1980) and it is
consistent with Shneidman’s conceptualiza-
tion of suicide as an escape from mental
pain. In addition, his concept of
self-destructive behaviors that are rooted in
cognitive distortion shares elements with
Shneidman’s ideas about faulty logic and
cognitive dichotomies in the mind of the
suicidal person (Shneidman, 1980).
A variety of indirect evidence provides
support for the escape theory (Dean & Range,
1999; Hunter & O’Connor, 2003; O’Connor
& O’Connor, 2003; Tassava & Ruderman,
1999). In particular, different observations
tend to corroborate the view that a major
disappointment in one’s self plays a major role
in precipitating suicidal behavior. Baumeister
and his colleagues (DeWall, Baumeister, &
Vohs, 2008; DeWall, Twenge, Koole et al.,
2011; Twenge, Catanese, & Baumeister,
2002, 2003) as well as other investigators
(Chatard & Selimbegović, 2011) also found
evidence for these notions. However, direct
evidence for the theory is rather sparse and
mostly tested in non-clinical populations.
The theory lacks specific assumptions and
support regarding when suicidal thoughts
emerge in the six-stage model. It also does
not deal with other motivations for escape
and impaired escape strategies (such as faulty
problem solving) or with cognitive and
emotional predispositions that underlie the
transition from one step to the next and
culminate in suicide. Nonetheless, the escape
theory is a prominent theory of suicidal
behavior (O’Connor, 2003), and influenced
other theoreticians to offer elaborations of
the theory, including Williams (1997) and
O’Connor (2011).
Arrested Flight Model (Cry of Pain)
Extending Baumeister’s definition of
suicide as a desire to escape from the self,
ARCHIVES OF SUICIDE RESEARCH
S. Barzilay and A. Apter
Williams (1997) posited that suicide is a
product of feelings of defeat in response
to humiliation or rejection which trigger
perceptions of entrapment, combined with
a failure to find alternative ways to solve
the problem. This model draws upon the
concept of arrested flight reported in the ani-
mal behavior literature and which has been
suggested to account for depression in
humans (Gilbert & Allan, 1998). Williams
and Pollock (2000, 2001) suggested that
when individuals perceive their attempts
at solving problems to be unsuccessful,
they feel powerless to escape from the
situation. The sense that the future holds
little opportunity for reprieve leads to
hopelessness. However, rescue factors
can moderate the relationship between
entrapment and suicide and thereby reduce
suicide risk.
Overall, Williams’s model views suicidal
behavior as a cry of pain rather than a cry for
help in response to an intolerable emotional
or situational state. The model is important
because it integrates psychobiological and
evolutionary factors, it emphasizes the
potential interactions between emotions
and cognitions in the road to suicide, and
highlights the role of entrapment and hope-
lessness in the development of suicidal
ideation and behavior (For an extensive
discussion of this model, see Johnson,
Gooding, & Tarrier, 2008.) The model has
been supported by studies that demon-
strated the importance of defeat and entrap-
ment (Gilbert & Allan, 1998; O’Connor,
2003; Rasmussen, Fraser, Gotz et al., 2010;
Rooke & Birchwood, 1998; Taylor, Wood
et al., 2010). Many studies have related poor
problem solving to suicide (see Pollock &
Williams, 1998, for a review). Williams and
Pollock described it as over-general autobio-
graphical memory, where a person faced
with a problem fails to access his past in
order to generate possible solutions. The
role of autobiographical memory in suicidal
behavior was supported in several studies
(Arie, Apter, Orbach et al., 2008; Evans,
299

Williams, O’Loughlin et al., 1992; Pollock &
Williams, 2001; Sinclair, Crane, Hawton et al.,
2007; Williams, Barnhofer, Crane et al.,
2005). Although suicide has been related to
some specific components of Williams’
theory, these components were not tested
simultaneously in one sample. In addition,
the theoretical model is limited by the
difficulty in separating the constructs of
hopelessness, depression, defeat, entrap-
ment, and suicidal ideation. For example,
several studies support the notion that defeat
and entrapment constitute a single construct
(Johnson, Tarrier, & Gooding, 2008;
Taylor, Wood, Gooding et al., 2009, Taylor,
Gooding et al., 2010). Although research
points to a strong relationship between
suicidal behavior, hopelessness, and lack of
social support or rescue, it is not clear how
they relate to each other, and no single
pathway can be inferred from the model
(Johnson, Gooding, & Tarrier, 2008).
COGNITIVE THEORIES
The Comprehensive Cognitive Model
Beck, Brown, Berchick et al. (1990)
emphasized the cognitive aspect of suicid-
ality. They suggested that hopelessness
plays a major role in suicide by disrupting
all components of the classic cognitive triad
of beliefs about self, others, and the future.
In a more recent study, Wenzel, Brown, &
Beck (2009) introduced the concept of
maladaptive schemas which consist of biases
in attention, information processing, and
memory. Suicide-relevant attention biases
result in selective processing of suicide-
relevant stimuli. Memory biases impair the
ability of the suicidal individual to recall
reasons for living or being hopeful about
his=her life. Wenzel and Beck (2008) for-
mulated a comprehensive model of suicide
wherein the interaction among three main
constructs lead to suicidal act: dispositional
vulnerability factors, cognitive processes
300 VOLUME 18  NUMBER 4  2014
Psychological Models of Suicide
associated with psychiatric disturbance,
and cognitive processes associated with sui-
cidal acts. Heightened vulnerability induced
by one’s disposition includes five main fac-
tors that have been supported by empirical
literature (impulsivity and aggression, prob-
lem solving deficits, an over-general mem-
ory style, a trait-like maladaptive cognitive
style, and other personality variables, parti-
cularly perfectionism and neuroticism).
Cognitive theory suggested that vulner-
ability factors interact with life stressors
and increase the likelihood of schemas
associated with psychiatric disturbance.
These schemas facilitate biased information
processing that underlies suicide. However,
suicidal individuals are also characterized
by suicide schemas that are specific to sui-
cidal behavior. In this cognitive model
there are two types of suicide schemas.
Non-impulsive attempts are those charac-
terized by chronic hopelessness, and impul-
sive attempts are those characterized by
perceptions of unbearability (Fawcett,
Busch, Jacobs et al., 1997).
The theories of Beck have had a sig-
nificant influence on the current under-
standing of suicidal behavior. Many of
the constructs included in the model have
an empirical basis (for extensive review
see Wenzel, Brown, & Beck, 2009). Studies
that assessed suicide-specific attention bias
among suicide attempters have used
cross-sectional designs (Becker, Strohbach,
& Rinck, 1999; Keilp, Gorlyn, Oquendo
et al., 2008; Malloy-Diniz, Neves, Abrantes
et al., 2009; Williams & Broadbent, 1986).
There was only one recent prospective
design that showed that attention bias pre-
cedes suicide attempt (Cha, Najmi, Park
et al., 2011). These findings suggested that
suicide-specific attention bias accelerates
the likelihood of suicide attempt. However,
there is still a need to test other aspects of
this theory and to empirically support the
mechanisms in which the factors are inter-
acted and mediated to increase suicidal
risk.

Fluid Vulnerability Theory
To explain the process of suicide risk,
Rudd (2006) proposed the fluid vulner-
ability theory. Beck (1996) used the term
mode to describe the cognitive processes
whereby individuals interpret external and
internal stimuli. Modes are structural net-
works of cognitive, affective, motivational,
physiological, and behavioral schemas that
are activated simultaneously by relevant
internal and external events. Repeated acti-
vation of a specific mode lowers the
threshold for its subsequent activation,
causing a unique vulnerability. Drawing
on Beck’s work, Rudd, Rajab, and Dahm
(2001) suggested a suicidal mode, defined as
combination of a suicidal belief system,
physiological-affective symptoms, and
associated behaviors and motivations. The
fluid vulnerability theory is based on the
assumption that suicidal episodes are
time-limited and the factors that trigger
the episode and contribute to its severity
and duration are fluid in nature. Rudd
believed that every individual has a baseline
vulnerability to suicide, which is determined
by a combination of cognitive susceptibility
(e.g., attention bias, over-general memory),
biological susceptibility (e.g., physiological
and affective symptoms) and behavioral
susceptibility (e.g., deficient skills in inter-
personal or regulation domains). Variations
in vulnerability account for the emergence
and chronicity of suicidality. The acute risk
is heightened in the presence of aggravating
risk factors. Core cognitive themes that acti-
vate the suicide mode are a belief of being
unloved, a belief that one is a burden to
others, feelings of helplessness, and inability
to tolerate distress, among others. The
constellation of themes that comprise a per-
son’s suicide mode may serve as predictors
of that person’s vulnerability to a suicidal
crisis, the probable triggers and duration
of the crisis, and the potential for future
crises. Individuals with a sensitive suicidal
belief system that can be activated by the
ARCHIVES OF SUICIDE RESEARCH
S. Barzilay and A. Apter
slightest provocation will suffer recurrent
crises, with each event increasing their
vulnerability for future crises. Indirect evi-
dence was found for some dispositional
traits. Cognitive vulnerabilities such as rumi-
nation (Surrence, Miranda, Marroquı́n et al.,
2009) and cognitive inflexibility (Miranda,
Gallagher, Bauchner et al., 2012) were found
to predict suicidal ideation. Other character-
istics have distinguished multiple attempters
from single attempters (Miranda, Scott,
Hicks et al., 2008). It was suggested that this
model is very helpful in the assessment of
suicidal patients by taking into account not
only acute risk factors (e.g., current suicidal
ideation) but also taking to account chronic
risk. However, the potential precipitants of
suicide are unclear, as is the manner in which
personality and genetic factors interact to
determine baseline levels of vulnerability.
To our knowledge, there has been no direct
examination of the theory including specific
assumptions for the cognitive vulnerabilities
that increase suicidal risk.
DIATHESIS-STRESS THEORIES
The diathesis-stress models postulate that
suicidal behavior occurs as a consequence
of the interaction between predisposing
vulnerability factors and a triggering stress
factor. Different theoreticians suggest dif-
ferent contexts for the vulnerability to sui-
cide and the stress involved in suicidal
behavior.
Social Problem-Solving Vulnerability
Schotte and Clum (1982, 1987) pro-
posed that cognitive rigidity in problem
solving causes a vulnerability to emergent
hopelessness and suicidal ideation under
naturally occurring conditions of high life
stress. Individuals with a low capacity for
flexible divergent thinking are unable to
identify alternative solutions to their
problems or tend to anticipate negative
301

consequences for any proposed solutions.
Therefore, when they experience life stress,
they tend to become more hopeless, heigh-
tening their risk for suicidal behavior.
This model shares ideas with other
psychological theories of suicide as the sol-
ution for problems due to a lack of other
options. It expands previous thinking by
highlighting interpersonal deficits, thereby
suggesting potential intervention strategies
focused on interpersonal problem solving.
Empirical research found that relative to
non-suicidal individuals, suicidal individuals
generate fewer solutions to problems
(Pollock & Williams, 2004), are less likely
to use the alternatives they generate
(Schotte & Clum, 1987), estimate a greater
likelihood of negative consequences asso-
ciated with proposed solutions (Schotte &
Clum, 1987), and are more likely to use
denial or avoidance strategies in dealing
with their problems (Orbach, Bar-Joseph,
& Dror, 1990). However, the problem-
solving deficits observed in suicidal indivi-
duals might be state-dependent rather than
a trait; that is, they may be a consequence
of negative life stress or depression. In addi-
tions, there is no one clear definition to
‘‘problem solving’’. When problem solving
was defined as the ability to generate mul-
tiple solutions to problems, it was associa-
ted with suicide ideation but not with
hopelessness (Schotte & Clum, 1982) and
interacted with stress to predict suicide
ideation over time (Priester & Clum,
1993). However, when problem solving
was defined as confidence in one’s ability
to solve problems, it was strongly associated
with hopelessness and moderately associa-
ted with suicide ideation (Dixon, Heppner,
& Anderson, 1991; Rudd, Rajab, & Dahm,
1994). Reinecke, DuBois, and Schultz
(2001) reported that depression and hope-
lessness mediated the link between problem
solving and suicidal ideation. Thus, it is
important to specify the precise type of
problem solving deficit under examination.
Other limitations include focus on suicide
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Psychological Models of Suicide
ideation as an outcome, rather than suicide
attempts, and use of non-clinical samples.
Overall, empirical research has not con-
firmed the mediational role of problem
solving deficits (e.g., Schotte & Clum,
1982), and therefore Wenzel and Beck
(2008) proposed a revised conceptualiza-
tion for the problem solving deficits related
to suicide. It was suggested to view
problem-solving deficits as a dispositional
characteristic that is associated with a host
of adverse outcomes, including psychiatric
disturbance and suicidal crises.
Clinical-Biological Model of Suicidal
Behavior
The clinical model of Mann, Apter,
Bertolote et al. (1999) and Mann,
Waternaux, Haas et al. (2005) suggests that
psychiatric illness serves as a stressor but
leads to suicide only when combined with
vulnerability. The theory is based on the
notion of impulsive aggression, or the tendency
to respond to provocation or frustration
with hostility or aggression, as a trait factor
and common correlate of suicidal behavior
(Bridge, Goldstein, & Brent, 2006). Impul-
sive aggression is increased by low seroto-
nergic activity and=or substance abuse,
potentiating the relationship between psy-
chopathology and suicidal actions. Brent
and Mann (2006) proposed that the vulner-
ability to suicidal behavior is often familial
with a likely genetic component, and impul-
sive aggression is a key to understanding
familial transmission. Specifically, parental
mood disorder and=or impulsive-aggressive
traits are transmitted to the child via genetics
or a suboptimal family environment (e.g.,
abuse and neglect). As a consequence, mood
disorder or impulsive aggression develops
in the child and may ultimately lead to
suicidal behavior in the presence of life
stressors.
The main contribution of this model
is its elaboration of background causal

pathways to the development of
stress-activated susceptibility to suicidal
behavior. It is well delineated and sup-
ported by empirical findings (Mann,
Arango, Avenevoli et al., 2009; Melhem,
Brent, Ziegler et al., 2007). Many studies
reported a link between impulsivity and
suicide (Brodsky, Malone, Ellis et al.,
1997; Kingsbury, Hawton, Steinhardt et al.,
1999; Mann, Waternaux, Haas et al., 1999;
Nock & Kessler, 2006) including evidence
that impulsive-aggressive suicide is more
common among young suicide attempters
and suicide completers (Brent & Mann,
2005; 2006). And the genetic influence
seems to be mediated many by serotonergic
mechanisms (Mann, 2013). However, sev-
eral studies have failed to find a significant
association between impulsivity and suicidal
behavior (Horesh, 2001; Keilp et al., 2006;
Oquendo, Waternaux, Brodsky et al.,
2000). Recent studies indicate that although
impulsivity is considered a risk factor for
suicidal behavior, death by suicide is not
necessarily an impulsive act. Witte, Merrill,
Stellrecht et al. (2008) reported that less than
one-fourth suicide attempters did so with-
out planning. It was also found that patients
who made impulsive suicide attempts scored
no higher on a self-report measure of impul-
sivity than patients who had planned their
attempts (Baca-Garcia, Diaz-Sastre, Garcia
Resa et al., 2005). Klonsky and May (2010)
explained these mixed findings by suggest-
ing that studies have utilized broad measures
of impulsivity that insufficiently differentiate
aspect of impulsivity, while only a specific
trait of diminished ability to think through
the consequences of one’s behavior before
acting confers risk for suicidal behavior
above and beyond suicidal ideation. Thus,
it is possible that impulsivity in and of itself
is a peripheral construct in understanding
suicidal behavior and there is need to ident-
ify more refined mechanism with more
explanatory power to account for suicidal
behavior (for a recent review see Gvion &
Apter, 2011).
ARCHIVES OF SUICIDE RESEARCH
S. Barzilay and A. Apter
Two-Stage Model of Outward and Inward
Directed Aggression
The two-stage model of suicide and
violence (Apter, Plutchik, & van Praag,
1993; Plutchik, 1995; Plutchik, van Praag,
& Conte 1989) is based on the assumption
that suicide and violence are expressions of
the same underlying aggressive impulse,
and it is the presence or absence of other
variables that determine what the direction
the aggression will take. Plutchik, van
Praag, and Conte (1989) listed possible
triggers (stressors) that generate aggressive
impulses, including threats, challenges,
insults, loss of control, and perceived threat
to one’s social rank. In the first stage, the
cutoff level of impulsive aggression that will
be expressed in overt behavior or action is
determined. Impulsive aggression may be
amplified or attenuated by other factors,
such as social support, attitudes toward
violence, and access to a weapon. In the
second stage, the object toward which the
aggression is directed is identified. The risk
of aggression towards the self (suicide) is
increased in the presence of depression,
total life problems, and recent psychopath-
ology symptoms. Impulsive trait and prob-
lems with the law direct the aggressive
impulse toward others (violence).
Multiple epidemiologic, clinical, retro-
spective, prospective, and family studies
have identified a strong link between
aggression and suicide (For a recent review
see Gvion & Apter, 2011). Direct examina-
tions of the two-stage model provided
some support (Apter, Plutchik, & van
Praag, 1993; Plutchik, 1995; Plutchik, van
Praag, & Conte, 1989). However, evidence
for relationships between psychopatholo-
gies and outward and inward aggression
is inconsistent (Spielberg, Reheiser, &
Sydeman, 1995; Whiteside & Abramovitz,
2004). Recent studies on suicide emphasized
the need to look at more specific aspects of
aggression when studying suicide attempts
(Giegling, Olgiati, Hartmann et al., 2009)
303

such as gender differences between trait
anger, anger expression, and suicide attempts
among adolescents and young adults
(Goldston, Reboussin, & Daniel, 2006).
From the theoretical perspective, this model
attempts to explain the impulsive-aggressive
type of suicidal behavior which seems to
occur more in younger people and has
received the most attention. However, other
personality constellations may underlie suici-
dal behavior, such as narcissist-perfectionist
type and hopelessness-depressive type
(Apter, 2010; Apter, King, Bleich et al.,
2008). These may well be associated with
different biosocial diatheses.
Interpersonal Theory of Suicide (IPTS)
The interpersonal theory of suicide
(Joiner, 2005) suggests that individuals will
engage in serious suicidal behavior if they
have both the desire to die and the capa-
bility to act on that desire (Joiner, 2005;
Van Orden, Witte, Cukrowicz et al.,
2010). The desire to die results from two
distinct interpersonal psychological states,
namely perceived burdensomeness, or a feeling
of being a burden to others, and thwarted
belongingness, or a feeling of alienation.
These feelings lead to the belief that one’s
death is worthwhile to others. When the
two states converge, suicidal ideation is
enhanced. However, this is not enough
for lethal suicide, as the desire to die may
be overcome by a sufficiently powerful
instinct of self-preservation. This qualifi-
cation is in line with the behavioral disinhi-
biting component of Baumeister’s theory,
and shares some elements with Orbach’s
(1996) ‘‘suicidal body,’’ According to Joiner
(2005), individuals acquire a fearlessness of
pain, injury, and death through a process of
repeatedly experiencing pain, often by
self-injury. He calls this an acquired capability
for suicide.
The interpersonal theory offers a
possible explanation for suicide attempts
304 VOLUME 18  NUMBER 4  2014
Psychological Models of Suicide
by people with a history of self-harm and
other risk behaviors. An important advan-
tage of the IPTS is that it is the first to dis-
tinguish individuals who think about suicide
without acting on those thoughts from indi-
viduals who translate suicidal ideation into
action. Joiner and his colleagues conducted
systematic empirical studies to examine spe-
cific components and interactions proposed
by the IPTS. Studies have found a signifi-
cant effect of thwarted belongingness and
perceived burdensomeness on suicidal idea-
tion (Conner, Britton, Sworts et al., 2007;
Jahn & Cukrowicz, 2011; Jahn, Cukrowicz,
Linton et al., 2011; Joiner, Schmidt,
Schmidt et al., 2002; Joiner, Van Orden,
Witte et al., 2009; Van Orden, Lynam, Hol-
lar et al., 2006; Van Orden, Witte, Gordon
et al., 2008; Van Orden, Witte, James et al.,
2008). However, contrary to IPTS hypoth-
eses, a meta-analysis of 192 studies on social
rejection concluded that social rejection
neither causes immediate distress nor
lowers self-esteem (Blackhart, Nelson,
Knowles et al., 2009).
In support of the hypothesis of
acquired capability for suicidal behavior, it
was found that a history of non-suicidal
self-injury and suicide attempts was related
to less fear about engaging in suicidal
behavior (Muehlenkamp & Gutierrez,
2007; Stanley, Gameroff, Michalsen et al.,
2001). Direct tests supported the link
between self-harm behaviors, acquired
capability, and eventually with suicide
attempts (Bender, Gordon, Bresin et al.,
2011; Joiner, Van Orden, Witte et al.,
2009; Selby, Smith, Bulik et al., 2010; Smith,
Ribeiro, Mikolajewski et al., 2012; Van
Orden, Witte, Cukrowicz et al., 2010; Van
Orden, Witte, Gordon et al., 2008). How-
ever, findings regarding increased pain
tolerance by non-suicidal self-injury showed
inconsistent results (Franklin, Hessel, &
Prinstein, 2011; Hooley, Ho, Slater et al.,
2010; Nock, Joiner, Gordon et al., 2006).
Therefore, although IPTS has received
increased support in recent years, there are

some theoretical and empirical limitations.
It remains unclear why acquired capabilities
do not always translate into completed sui-
cide. In addition, the range of experiences
that contribute to self-injury habituation is
unclear, as well as their relative power
(Van Orden et al., 2010). The theory also
fails to account for the central role of
psychopathologies, such as depression, in
completed suicide. Research has also been
limited by cross-sectional study designs
and in testing the simultaneous effect of
all three factors of the IPTS and the
interrelations among them.
Integrated Motivational-Volitional Model
of Suicide Behavior (IMV)
In an attempt to incorporate the major
components of previous theoretical
models and empirical evidence, O’Connor
(2011) suggested the three-phase integrated
motivational-volitional model of suicidal
behavior. The model emphasizes the inter-
play between factors associated with the
development of suicidal ideation and the
translation of these thoughts into suicidal
behavior. The premotivational phase consists
of background factors (e.g., environmental
deprivation, vulnerabilities) and triggering
life events that provide the biosocial con-
text for suicide, and the motivational phase
consists of factors associated with the for-
mation of suicidal thoughts and intention
to end one’s life. The theory posits, as
adapted from the model of Williams
(1997), that suicidal ideation derives from
feelings of entrapment that are triggered
by experiences of defeat and humiliation.
Feelings of entrapment are exacerbated by
specific state moderators, such as poor
coping strategies, poor problem solving,
and attribution biases. In the presence of
motivational moderators such as interper-
sonal states and impaired subjective goals,
norms, and future positive thinking, they
lead to suicidal ideation. In the third
volitional phase, the suicidal thoughts are
ARCHIVES OF SUICIDE RESEARCH
S. Barzilay and A. Apter
translated into actual suicidal behaviors.
The transition is determined by behavioral
enaction factors, as identified in the theory
of planned behavior (Ajzen, 1991), cry of
pain model (Williams, 1997), and the inter-
personal theory of suicide (Joiner, 2005).
Examples include access to means of
suicide, capability to attempt suicide,
imitation, and impulsivity.
This model is important because it
builds on existing evidence and theoretical
knowledge. It integrates aspects of differ-
ent psychological theories and provides a
theoretical map of how distal risk may be
translated into suicidal behavior via proxi-
mal psychological risk processes. Recent
tests of the IMV model provided support
for some of its assumptions (O’Connor,
O’Carroll, Ryan et al., 2012; O’Connor,
Rasmussen, & Hawton, 2009, 2012).
Although findings are promising, the
results are limited in their generalizability
and there is a need to further test the
IMV model in other samples and settings.
Moreover, there is some conceptual con-
fusion. For example, the constructs of
defeat and entrapment, may overlap. In
addition, only several assumptions of the
model were examined and more refined
hypotheses suggested by the model and
the specificity of the moderators of each
step remains to be empirically tested.
SUMMARY AND CONCLUSIONS
Psychological theories of suicidal behavior
have increased in number and complexity
over the last decades and have potential
important implications for research and
the development of methods of suicide
prevention. The early psychoanalytic
models had a great influence in generating
interest and hypothesis about the field.
They have not, however, generated much
empirical research with practical implica-
tions for treatment and prevention apart
from the pioneering efforts of Orbach
(1996). Nonetheless, there has been a recent
305

resurgence of interest in the empirical
investigations of psychoanalytic theories
and some evidence was found for the
psychodynamic formulations of suicide
(Fowler, Hilsenroth, Groat et al., 2012;
Maltsberger, 2004). Development of con-
temporary psychological models based on
empirical research has been stimulated by
the influential work of Shneidman and by
exponents of the cognitive and behaviorally
oriented approaches. These psychological
models have provided valuable insights into
the suicidal mind. Some models focused on
vulnerability factors that are related to sui-
cide, including impulsive-aggressive tenden-
cies, maladaptive cognitive styles, attention
bias, over-general memory, problem solving
deficits, and acquired capability for self-
harm. Other models focused on the situa-
tional perceived stress leading an individual
towards a suicidal act. Such theories center
on mental pain, hopelessness, entrapment,
and interpersonal distress. Few theories
have attempted to integrate both diathesis
and stress related factors.
However, most of the models proposed
so far are limited in several ways. From the
theoretical perspective, the main short-
coming of most models is that they have a
narrow focus and are not sufficiently com-
prehensive to account for all the correlated
factors identified in empirical studies of
suicide behavior. It is not yet clear as to
how the components interact with and are
mediated by established risk factors to
elevate or lower risk for suicidal behavior
in all its complexity. For example, most of
the existing conceptual frameworks such
as those of Baumeister and Williams are pre-
dominantly non-developmental and fail to
address background factors and causal path-
ways that increase vulnerability. Second, in
many of the models there is no generally
accepted understanding and clear definition
of the main constructs. For example,
there are different conceptualizations for
psychological pain, impulsivity, and
problem-solving. At the same time, there
306 VOLUME 18  NUMBER 4  2014
Psychological Models of Suicide
is a considerable conceptual communality
across the various models. It seems that
independent theoreticians use different
terms for similar or overlapping ideas. It
can be argued that psychache, hopelessness,
defeat, entrapment etc. are not independent
from each other. Therefore important
advances in the field could be achieved by
integrating the disparate as well as the
common perspectives and to refine them
into a comprehensive unified approach.
Such an attempt has been recently proposed
by O’Connor (2011). A comprehensive
model should address the interplay among
multiple contextual factors on different
levels of analysis (e.g., physiologic, cogni-
tive, social), state-related motivation for
suicide both in the intra-psychic and inter-
personal domains, and factors involved in
translation of the death wish into actions.
In addition to risk factors, protective factors
need to be addressed as well (Brent, 2011).
From the empirical perspective, most
research has been limited by giving support
for only some of the respective model’s
components but not all. Furthermore, many
of the models that were reviewed rely on
indirect evidence and direct tests of the mod-
els are extremely rare. When direct evidence
was offered, most studies used cross-
sectional designs and were limited to specific
populations and settings. Therefore there is a
need for further research with larger sample
sizes in different populations (both com-
munity and high risk samples) and longitudi-
nal designs. Data analytic approaches that
will allow for evaluating more refined mech-
anism while testing the interrelations among
all the theory components simultaneously
will be a major contribution to the existing
knowledge. Better understanding of the
causal mechanisms will lead to improved
intervention strategies.
AUTHOR NOTE
Shira Barzilay and Alan Apter, Feinberg
Child Study Center, Schneider Children’s

Medical Center of Israel, Petach Tikva,
and Sackler School of Medicine, Tel Aviv
University, Tel Aviv, Israel.
Correspondence concerning this article
should be addressed to Shira Barzilay,
Feinberg Child Study Center, Schneider
Children’s Medical Center of Israel, Petach
Tikva 49202, Israel. E-mail: shirabarzilay@
gmail.com
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