Michelle M. Cornette, Medical College of Wisconsin
Andrew M. Busch, University of Wisconsin — Milwaukee
“Stress” is a well-known contributor to mood, mental disorders, and suicide risk. Stress is a term often used synonymously with negative life experiences, or life events. Negative life events conferring risk for depression, suicidal thinking, and behavior, includes interpersonal, occupational, and traumatic childhood events. Trauma, especially childhood trauma, has significant short and long-term impact on risk for suicidal behavior. Specifically, child abuse (emotional, sexual, and physical), parental death, parental mental illness, and witnessing domestic violence during childhood have all been linked to suicidal behavior, both acutely, and over longer time intervals.
Interpersonal life event also increase risk for suicidal behavior. Parental or spousal death, serious arguments with a spouse, and social "exit events" (e.g. a child leaving home) have been linked to suicide attempts among adults, while parental separation and relationship break-ups have been linked to suicide among adolescents and young adults. The interpersonal events most relevant to suicidal behavior appear to be those involving loss or conflict in existing interpersonal relationships, rather than simple social isolation.
Negative occupational and academic events also increase risk for suicidal behavior. Specifically, occupational loss and other difficulties at work have been linked to completed suicide. Unemployment and financial strain are also common among those who commit suicide. Among adolescents and young adults, failing a grade, suspension from school, and drop-out have all been linked to later suicide. Interestingly, objectively neutral and even positive life events to include marriage/ engagement, birth of a child or other new person in the home, and relocation, can also increase stress and risk for suicidal behavior.
Recent research in college students, older adults, outpatient clinic samples, and military veterans suggests that events which lead one to feel burdensome on others (e.g. job loss, physical illness, or other role transition) may be particularly important risk factors for suicidal behavior. For example, research has revealed that suicide notes from individuals completing suicide contain more references to perceived burden than the notes of individuals attempting suicide.
Emotional Stress
Stressful life events can also contribute to subjective experiences of feeling “stressed”, meaning “anxious”. Anxious mood often represents a fear of anticipated negative events (as those listed above) which have yet to occur. Though depression-spectrum diagnoses are important contributors to suicidal ideation and behavior, anxiety disorders are also important risk factors for suicide. Some have argued that the co-occurrence of both anxiety and depressive-spectrum disorders confer greatest risk for suicidal thinking and behavior than depression alone. Anger, another contributor to suicidal thinking, is often preceded by life experiences which induce frustration, as may occur following perceived injustices or feeling misunderstood. Higher-order emotions such as shame and guilt, and the life experiences which contribute to these emotions, may also increase risk for suicidal thinking.
Factors Influencing the Extent to Which Life Events Affect Us
Though many individuals experience varying degrees of life “stress”, some individuals are more vulnerable to the effects of stress on their mood and depressed/ suicidal thinking. Specifically, a number of cognitive risk factors, to include interpersonal problem-solving deficits, perfectionism, hopelessness, and other distorted cognitions, may influence how and to what extent negative life events influence our mood and potential for suicidal thinking.
Many suicidal individuals are less skilled at solving interpersonal problems than non-suicidal individuals. Thus, when individuals prone to suicidal thinking are faced with interpersonal dilemmas, research suggests they may have greater difficulty coping. The latest research further suggests that suicidal people have less clear memories about their interpersonal pasts, perhaps one reason for the more limited interpersonal problem-solving ability—e.g. suicide-prone individuals may be less likely to draw upon previously generated solutions, leaving them at a loss for alternatives and rendering them more vulnerable to feelings of hopelessness, emotional distress, and suicidal thoughts.
Research also supports the idea that suicidal individuals may hold higher standards for themselves than the average person. These elevated standards, which at worst may manifest as perfectionism, may leave individuals vulnerable to perceptions of failure and ultimately to thoughts of hopelessness and suicide.
Hopelessness — the perception that one’s negative life circumstances are unlikely to improve, or that there is no way to solve an important problem or escape psychological pain, can also mediate the relationship between stressful life events and suicidal behavior. Hopelessness has been defined as the social cognitive risk factor “most consistently related to suicide ideation, intent, and completion” in both adult and child clinical populations. Research has suggested that hopelessness may be a stronger predictor of completed suicide than depression, and that hopelessness predicts eventual suicide over periods of 10 years or more in adult psychiatric inpatients and outpatients.
Also important are styles of thinking which influence the manner in which we interpret negative and positive events in our lives. A limited body of research suggests that social cognitive distortions—e.g. tendencies to generalize the consequences of a negative life event, or engage in black-and-white thinking — contribute to suicide risk.
What Causes Some Individuals To Be At Greater Risk Than Others?
What factors determine which individuals are most likely to develop the sorts of cognitive vulnerabilities noted above? One’s propensity for developing one of more of these cognitive vulnerabilities can be increased through developmental, social, neurochemical, and genetic influences. Importantly, biological, genetic, and psychosocial risk factors for suicide may in many cases not confer risk directly, but indirectly, through mental illness (to include depressive disorders, anxiety disorders, substance use disorders, and psychosis), which ultimately increase risk for suicidal behavior.
Can Specific Events Be Blamed for Suicidal Behavior?
Some individuals question whether, following a completed suicide, a specific event can be identified as the specific “cause” of the suicide. While certain events may act as precipitants, it is believed that a cluster of predisposing factors come together to culminate in suicide risk. Mental illness, for example, is thought to contribute to suicide risk in at least 90% of completed suicides. Factors such as availability of means for suicide are also important.
What Can One Do?
How can one be attentive to and reduce their levels of emotional stress? Maintaining a degree of self-awareness and working to establish a rich social support network is an important piece. Equally important is openness to the idea of seeking professional help, in the form of psychotherapy, pharmacotherapy, or both, and willingness to encourage others to do so when they appear to be having particular difficulty coping with life stress, or are more generally expressing feelings of depression or suicidal thinking.
Some forms of psychotherapy more directly address stressful life experiences by teaching social skills to enhance social support and increase the likelihood of positive life experiences, and by teaching problem-solving skills which help patients identify solutions to interpersonal and other problems. Yet life stress is inevitable, and therefore, learning strategies for reducing and dealing with life stress are critical to mental health. To this end, cognitive behavioral therapy, which has been identified as an effective treatment for depression, anxiety, and related forms of mental illness, works on modifying pessimistic and other forms of distorted thinking. A cognitive-behaviorally-based psychotherapy which is specific in its treatment of symptoms of suicide and of the specific proximal risk factors preceding suicidal behaviors (e.g. hopelessness, poor problem solving, poor impulse control, noncompliance with the health system, social isolation, etc.) has recently been developed. Cognitive coping strategies include modifying suicide-relevant beliefs, building problem-solving skills, identifying reasons for living, creating coping cards, and reducing impulsivity.
More behavioral approaches aimed at increasing one’s involvement in pleasurable or meaningful activities can be helpful in treating depressed mood. Relaxation training is another recommended treatment for dealing with anxiety, another contributor to suicidal thinking and behavior.
In addition, dialectical behavior therapy, which incorporates problem-solving and other cognitive-behavioral strategies, has demonstrated efficacy in reducing suicidal symptoms among individuals with borderline personality disorder.
Summary
Life stressors, to include experiences of childhood trauma, interpersonal, and occupational/ academic events, are important risk factors for suicide. Recent research suggests that events which lead individuals to feel burdensome on others may be particularly important. Some positive events have also been found to confer risk for suicidal behavior. Yet stressors are not experienced similarly by all people—interpersonal problem-solving deficits, autobiographical memory deficits, and cognitive distortions lead some individuals to be more vulnerable to the influences of negative life events. Propensity for developing these cognitive vulnerabilities is thought to be influenced by developmental, social, neurochemical, and genetic factors.
Stressful life events can also contribute to subjective experiences of feeling “stressed” — an anxious mood state or anxiety disorder. Depression-spectrum diagnoses are also important contributors to suicide risk, and some argue that the combination of a depression and anxiety state or disorder puts individuals at particularly high risk for suicidal behavior. Both life events and cognitive vulnerabilities may confer risk for suicidal thinking, directly as well as through mediating emotional states and psychiatric disorders.
Treatment, in the form of both psychotherapy and pharmacotherapy, for dealing with emotional distress and suicidal thoughts secondary to life stress are available.