(青少年網(wǎng)絡(luò)心理與行為教育部重點(diǎn)實(shí)驗(yàn)室,華中師范大學(xué)心理學(xué)院,湖北省人的發(fā)展與心理健康重點(diǎn)實(shí)驗(yàn)室,武漢430079)

自殺行為(suicidal behavior),包括與自殺有關(guān)的想法、非致命性自殺企圖和致命性的自殺(Silverman,Berman,Sanddal,O'Carroll,&Joiner,2007)。自殺行為,不僅讓每個(gè)家庭遭受巨大的悲痛,也對(duì)社會(huì)造成極大的負(fù)面影響。研究者們一直致力于找出自殺行為的影響因素,近10年以來相關(guān)研究迅速增加。以“suicide”為檢索詞在美國心理學(xué)會(huì)期刊全文數(shù)據(jù)庫(EBSCO PsychARTICLES)中搜索,1995～2004年期間出版的文章有15325篇,2005年至今已增至有 30247篇。與此相比,國內(nèi)的自殺研究起步較晚,尚未引起多數(shù)研究者及實(shí)踐者的關(guān)注。

因此,本文將對(duì)國外該領(lǐng)域的主要研究內(nèi)容進(jìn)行評(píng)述性介紹,包括概念界定、流行病學(xué)調(diào)查結(jié)果、自殺行為的影響因素及理論模型構(gòu)建,并指出未來研究方向,供國內(nèi)同仁參考。

1 術(shù)語及概念界定

自殺行為主要包括自殺意念、自殺企圖和自殺。然而,自殺行為研究領(lǐng)域中并非僅有這 3個(gè)術(shù)語。有研究者統(tǒng)計(jì),自殺意念的術(shù)語有 9個(gè),如：suicidal ideation、suicidal thoughts、suicidal ideology與suicidal preoccupations;自殺企圖的術(shù)語有36個(gè)之多,如：suicidal attempt、deliberate self-harm、non-lethal suicide與parasuicide等;而自殺的術(shù)語有 27 個(gè),如：suicide、committed suicide、completed suicide、lethal suicide attempt與self-inflicted suicide等(Silverman,2006)。其中,suicidal ideation、suicdal attempet和suicide出現(xiàn)頻率最高。

在概念界定方面,自殺意念是指那些喪失活下去的愿望,但還沒有導(dǎo)致身體受傷的自殺構(gòu)想與行為(Beck et al.,1973);自殺企圖是指非致命性結(jié)果的自我傷害行為,具有一定程度的自殺意圖,其結(jié)果可能是受傷或沒有受傷(O'Carroll et al.,1996)。相對(duì)而言,自殺的定義尚未統(tǒng)一。有研究者統(tǒng)計(jì)發(fā)現(xiàn),自殺的定義有15個(gè)之多,這些定義理論背景各不相同,如：社會(huì)學(xué)、心理學(xué)、精神病學(xué)、哲學(xué)及公共衛(wèi)生(De Leo,Burgis,Bertolote,Kerkhof,&Bille-Brahe,2006;Silverman,2006)。雖然自殺的定義繁多,但研究者逐漸在 3個(gè)方面達(dá)成共識(shí)：(1)自己造成的;(2)有意的;(3)結(jié)果具有致命性(De Leo et al.,2006;Maru?i?,2004)。

2 流行病學(xué)

由于樣本與調(diào)查工具的不同,中西方的自殺意念發(fā)生率存在一定差異。西方多采用單項(xiàng)目調(diào)查,如“是否嚴(yán)肅考慮過殺死自己？”(Crosby,Han,Ortega,Parks,&Gfroerer,2011)。我國多采用問卷調(diào)查,如“Beck自殺意念量表”、“積極與消極自殺意念問卷”。西方調(diào)查結(jié)果表明,自殺意念的發(fā)生率在18歲以下約為15～30.8%(Kokkevi,Rotsika,Arapaki,&Richardson,2012;Nock et al.,2008),18歲之后急劇下降,約為3.7～14.3%(Crosby et al.,2011;Nock et al.,2008)。我國的調(diào)查結(jié)果表明,大學(xué)生的自殺意念發(fā)生率為12.9～20.5%(李獻(xiàn)云等,2011;梁瑛楠,楊麗珠,2011);社區(qū)人群的自殺意念發(fā)生率為7.9%(李獻(xiàn)云等,2010)。

西方18歲以下人群中,自殺企圖的發(fā)生率約為3.1～8.8%,18歲以上為1.9～8.7%(Nock et al.,2008)。我國18歲以上人群中,自殺企圖的發(fā)生率在河北省為 0.82%(孫秀麗等,2010),廈門市為0.55%(王文強(qiáng),丁麗君,溫程,廖震華,吳素英,2012),顯著低于西方國家。

盡管中西方的自殺意念與自殺企圖的發(fā)生率不同,但調(diào)查結(jié)果一致表明,女性的自殺意念與自殺企圖的發(fā)生率均顯著高于男性(Crosby et al.,2011;Nock et al.,2008;梁瑛楠,楊麗珠,2011;孫秀麗等,2010;王文強(qiáng)等,2012)。

WHO(2014)的統(tǒng)計(jì)數(shù)據(jù)表明,2012年全球范圍內(nèi)總體自殺率約十萬分之 11.4,15歲以下的人群自殺率最低,而70歲以上的自殺率最高,男性的自殺率顯著高于女性,其比率約為3:1。Phillips,Li和Zhang(2002)的調(diào)查結(jié)果表明,1995～1999年我國的自殺率為十萬分之 23.2,女性自殺率高出男性25%。Wang,Chan和Yip(2014)的調(diào)查結(jié)果表明,2009～2011年我國的自殺率約為十萬分之9.8,男性略高于女性。兩項(xiàng)調(diào)查一致表明,老年人的自殺率最高,尤其是農(nóng)村老年居民。與西方國家相比,近年來我國的自殺特點(diǎn)是：(1)自殺率顯著下降,尤其是女性;(2)農(nóng)村自殺率始終高于城市;(3)老年居民是自殺的高危人群。

3 主要影響因素

目前,研究發(fā)現(xiàn)自殺行為的影響因素眾多(O'Connor &Nock,2014;van Heeringen &Mann,2014),大致可以分為三類：生物學(xué)因素、精神障礙和心理因素。

3.1 生物學(xué)因素

雙生子研究和家族研究均表明遺傳對(duì)自殺行為有重要的影響(Geulayov,Gunnell,Holmen,&Metcalfe,2012;Pedersen &Fiske,2010)。有研究表明,約30～50%的自殺風(fēng)險(xiǎn)是遺傳因素造成,然而特定的基因尚未確定(van Heeringen &Mann,2014)。

盡管目前尚未確定是哪些基因影響著自殺行為,但研究者發(fā)現(xiàn)與自殺行為相關(guān)的生物學(xué)因素會(huì)增加基因與環(huán)境的相互作用(van Heeringen &Mann,2014)。抑制神經(jīng)傳遞的血清素功能紊亂是與自殺行為聯(lián)系最密切的生物學(xué)因素(Antypa,Serretti,&Rujescu,2013)。然而,抑郁和沖動(dòng)暴力行為同樣存在著血清素激活功能不足(Bortolato et al.,2013;Mann,2013)。因此,這并非自殺行為所獨(dú)有的生物學(xué)現(xiàn)象。

3.2 精神障礙

約 90%的自殺死亡者中至少有一種精神障礙(Bertolote,2003;Cavanagh,Carson,Sharpe,&Lawrie,2003)。Harris和 Barraclough(1997)對(duì) 249篇自殺死亡與精神障礙有關(guān)的文獻(xiàn)進(jìn)行元分析,發(fā)現(xiàn)44種精神障礙中有36種會(huì)顯著增加自殺率。依據(jù)病因?qū)⒕裾系K分為三類：器質(zhì)性異常、物質(zhì)濫用障礙和功能性精神障礙,三者的自殺死亡比率為1:2:4(Harris &Barralough,1997)。

自殺者最常見的精神障礙是抑郁癥(Conner et al.,2013;Rihmer,2011;Slama,Merle,Ursulet,Charles-Nicolas,&Ballon,2011)。50%以上的自殺死亡者為抑郁癥(Bertolote,2003),20～48%的自殺企圖者為抑郁癥(Oquendo,Lizardi,Greenwald,Weissman,&Mann,2004;Slama et al.,2011;Suokas et al.,2010),而抑郁癥患者死于自殺的比率為2.2～6.2%(Bostwick &Pankratz,2000;Qin,2011)。Harris和Barraclough(1997)的元分析表明,控制人口學(xué)特征后抑郁患者中死于自殺的風(fēng)險(xiǎn)是非抑郁患者的20倍。血清素功能失調(diào)可能是抑郁癥與自殺密切相關(guān)的生理基礎(chǔ)(Mann,2013),而絕望也許是連接二者的重要心理因素。

除抑郁癥外,精神分裂癥、驚恐障礙、物質(zhì)濫用及邊緣型人格障礙患者也具有較高的自殺風(fēng)險(xiǎn)(Blasco-Fontecilla et al.,2009;Harris &Barralough,1997;Palmer,Pankratz,&Bostwick,2005;Pompili,Girardi,Ruberto,&Tatarelli,2005)。實(shí)際上,Harris和 Barraclough(1997)的元分析發(fā)現(xiàn)除了智力遲鈍、癡呆和曠野恐怖癥,幾乎所有的精神障礙都會(huì)增加自殺的風(fēng)險(xiǎn)。并且,精神障礙共病的數(shù)量越多,自殺風(fēng)險(xiǎn)就越高(Nock,Hwang,Sampson,&Kessler,2010),甚至共病的數(shù)量比共病的類型更具有預(yù)測力(Kessler,Borges,&Walters,1999)。

3.3 心理因素

盡管 90%的自殺者有精神障礙,但精神障礙患者中自殺的比率僅有5%(Bostwick &Pankratz,2000)。大部分精神障礙患者并不會(huì)自殺,甚至沒有自殺企圖。研究者認(rèn)為,心理因素能解釋為何有些人會(huì)自殺,而另一些人卻不這樣。從人格、認(rèn)知和情緒情感的角度對(duì)影響自殺行為的心理因素進(jìn)行梳理,可以分為：易損特質(zhì)、失調(diào)認(rèn)知和心理痛苦。

3.3.1 易損特質(zhì)

自殺行為的易損特質(zhì)主要是指與人格特質(zhì)有關(guān)的完美主義及沖動(dòng)性。易損特質(zhì)為自殺行為的發(fā)生提供素質(zhì)基礎(chǔ)。

(1) 完美主義

完美主義是指個(gè)體追求凡事都做到盡善盡美的傾向,為自己或他人設(shè)定了不切實(shí)際的高標(biāo)準(zhǔn),且以是否達(dá)到這些標(biāo)準(zhǔn)來對(duì)自己或他人作出評(píng)價(jià)。完美主義有3個(gè)維度：自我取向、他人取向和社會(huì)決定(Hewitt &Flett,1991)。O’Connor(2007)回顧了 29篇完美主義與自殺的研究,發(fā)現(xiàn)社會(huì)決定完美主義與自殺行為的關(guān)系密切,而其他維度的完美主義與自殺行為的關(guān)系并不一致。并且,多項(xiàng)研究表明,在控制抑郁與絕望后,社會(huì)決定完美主義與自殺行為仍有顯著相關(guān)(Dean,Range,&Goggin,1996;Hewitt,Flett,&Weber,1994),甚至能預(yù)測 6個(gè)月后的自殺意念(Beevers&Miller,2004)。

此外,完美主義與其他影響因素相互作用,共同增加自殺行為的風(fēng)險(xiǎn)。研究表明,面臨生活壓力與學(xué)業(yè)困難,社會(huì)決定完美主義水平較高者的自殺意念較多(Blankstein,Lumley,&Crawford,2007;Hewitt et al.,1994)。社會(huì)決定完美主義對(duì)行為抑制動(dòng)機(jī)與自殺意念起中介作用(Rasmussen,Elliott,&O'Connor,2012)。社會(huì)決定完美主義與過度概括化記憶的交互作用能預(yù)測自殺意念(Rasmussen,O'Connor,&Brodie,2008)。而 Wang,Wong和 Fu(2013)的研究發(fā)現(xiàn),完美主義增加了累贅感和未滿足的歸屬感對(duì)自殺意念的影響。

(2) 沖動(dòng)性

美國自殺協(xié)會(huì)(American Association of Suicidology)將沖動(dòng)性列為自殺的風(fēng)險(xiǎn)因子。然而,沖動(dòng)性與自殺的關(guān)系是模棱兩可的(Wenzel,Brown,&Beck,2009)。

多項(xiàng)研究表明,沖動(dòng)性與自殺行為有密切的聯(lián)系(Doihara et al.,2012;Klonsky &May,2010;Nock &Kessler,2006)。然而,也有研究發(fā)現(xiàn),沖動(dòng)型自殺行為與自殺者的沖動(dòng)性特質(zhì)之間沒有顯著的相關(guān)(Baca-Garcia et al.,2005;Giegling et al.,2009;Wyder &De Leo,2007)。甚至,有計(jì)劃的自殺組沖動(dòng)性特質(zhì)水平高于無計(jì)劃的自殺組(Witte et al.,2008)。

造成這種不確定關(guān)系的原因可能有兩個(gè)：第一,特質(zhì)沖動(dòng)與狀態(tài)沖動(dòng)二者之間存在差異。特質(zhì)沖動(dòng)是個(gè)體快速?zèng)Q策,不計(jì)后果,也無事先的計(jì)劃(Wenzel et al.,2009),而狀態(tài)特質(zhì)是個(gè)體在特定情境下的行為風(fēng)格(Dougherty et al.,2004;Swann et al.,2005)。因此,沖動(dòng)型自殺與自殺者沖動(dòng)性有重疊,但不完全相同。第二,沖動(dòng)性與自殺之間還存在其他變量。有研究發(fā)現(xiàn),沖動(dòng)性在痛苦與刺激事件及獲得自殺能力之間起中介作用(Bender,Gordon,Bresin,&Joiner,2011),而自殺能力是自殺企圖和自殺的影響因素(van Orden et al.,2010)。

3.3.2 失調(diào)認(rèn)知

失調(diào)的認(rèn)知包括兩個(gè)方面的內(nèi)容：(1)不良的認(rèn)知圖式,如：絕望;(2)偏差的認(rèn)知加工方式,如：認(rèn)知僵化、過度概括的自傳記憶和問題解決不足。

(1) 絕望

絕望是指對(duì)獲得某種目標(biāo)有較低的期待,以及對(duì)獲得成功有較少信念,是一種對(duì)未來消極期待的認(rèn)知圖式(Beck,Weissman,Lester,&Trexler,1974)。McMillan,Gilbody,Beresford和 Neilly(2007)的元分析發(fā)現(xiàn)絕望至少會(huì)增加 3倍的最終自殺風(fēng)險(xiǎn)?？刂埔钟羲胶?絕望與自殺意念及自殺企圖仍有顯著相關(guān)(Panagioti,Gooding,&Tarrier,2012;Suominen,Isomets?,Ostamo,&L?nnqvist,2004)。這說明,絕望與自殺的關(guān)系并非抑郁所致。并且,持續(xù)穩(wěn)定的絕望相對(duì)偶然一次的絕望更能預(yù)測自殺行為(Dahlsgaard,Beck,&Brown,1998;Young et al.,1996)。

然而,絕望預(yù)測自殺的追蹤研究結(jié)果并不一致。Beck,Steer,Kovacs和Garrison(1985)對(duì)有自殺意念住院患者進(jìn)行長達(dá)10年的追蹤研究,發(fā)現(xiàn)絕望預(yù)測自殺的準(zhǔn)確性高達(dá) 91%。Sokero等人(2006)為期 26周的追蹤研究發(fā)現(xiàn),控制抑郁水平后,絕望仍能預(yù)測自殺意念。但是有兩項(xiàng)長達(dá) 10年以上的追蹤研究表明,絕望并不能預(yù)測最終的自殺(Beck &Steer,1989;Suominen et al.,2004)。另有研究發(fā)現(xiàn),絕望與自殺意念存在強(qiáng)烈的同步關(guān)系,而非預(yù)測縱向關(guān)系(Shahar,Bareket,Rudd,&Joiner,2006)。這說明絕望可能是自殺的伴隨狀態(tài),而非因果關(guān)系。

與此同時(shí),一些研究者將目光投向“希望”,一個(gè)與絕望相對(duì)的概念。希望是指一種基于內(nèi)在成功感的積極動(dòng)機(jī)狀態(tài),由意愿動(dòng)力和路徑兩部分組成(Snyder,1995)。希望并非絕望的反向情感,低希望意味著對(duì)未來缺乏積極情感,而絕望則意味著對(duì)未來有較多的消極情感(Snyder et al.,1991)。已有的研究表明,希望與自殺意念呈顯著負(fù)相關(guān)(Davidson,Wingate,Slish,&Rasmus,2010;O'Keefe &Wingate,2013;安靜等,2012),并且希望能調(diào)節(jié)反芻與自殺意念的關(guān)系(Tucker et al.,2013;劉旺,田麗麗,陸紅,2014)。這說明希望能起到減少自殺意念發(fā)生的可能性。

(2) 認(rèn)知僵化

認(rèn)知僵化是指不能適應(yīng)外在反饋及環(huán)境因素來改變決策行為。臨床和理論研究者發(fā)現(xiàn),自殺者認(rèn)知僵化,他們認(rèn)為自殺是唯一的選擇。Marzuk,Hartwell,Leon和Portera(2005)以抑郁癥患者為被試,控制早期自殺企圖的次數(shù)、年齡、抑郁及言語智力后,發(fā)現(xiàn)當(dāng)前有自殺意念組的認(rèn)知僵化水平顯著高于無自殺意念組。同樣以抑郁患者為被試,自殺企圖組比起無自殺企圖組的認(rèn)知僵化水平更高(Keilp et al.,2013)。還有研究發(fā)現(xiàn),自殺方式的致命程度較高者,認(rèn)知僵化水平也比較高(Keilp et al.,2001)。

追蹤研究發(fā)現(xiàn),早期有過自殺企圖的個(gè)體,認(rèn)知僵化能預(yù)測 6個(gè)月后的自殺意念(Miranda,Gallagher,Bauchner,Vaysman,&Marroquin,2012)。另一項(xiàng)研究發(fā)現(xiàn),認(rèn)知僵化能預(yù)測 2～3年后的自殺意念,并且認(rèn)知僵化增加更多的反芻與絕望,進(jìn)而產(chǎn)生更多的自殺意念(Miranda,Valderrama,Tsypes,Gadol,&Gallagher,2013)。

(3) 過度概括的自傳記憶

自傳記憶(autobiographical memory)是個(gè)人對(duì)過去生活事件的回憶(Rubin,2005)。多項(xiàng)研究表明,自殺者具有過度概括的自傳記憶特點(diǎn)(Williams,Barnhofer,Crane,&Beck,2005;Williams et al.,2007;Williams &Broadbent,1986;Williams &Dritschel,1988)。

然而,過度概括化的自傳記憶并非僅限于自殺者。Williams等(2007)元分析發(fā)現(xiàn),抑郁、創(chuàng)傷性應(yīng)激障礙與過度概括的自傳記憶也有著穩(wěn)定的聯(lián)系。Leibetseder,Rohrer,Mackinger和Fartacek(2006)試圖進(jìn)一步了解抑郁、自殺和自傳記憶之間的關(guān)系,發(fā)現(xiàn)重度抑郁癥患者(無論有無自殺企圖)與有過自殺企圖者(但沒有情感障礙)相比,提取具體自傳記憶時(shí)受損情況相同。這說明,過度概括的自傳記憶是自殺與抑郁的共同易損因子。但依據(jù)當(dāng)前的研究結(jié)果,難以發(fā)現(xiàn)精神障礙(尤其是抑郁癥)對(duì)自殺者的自傳記憶受損是否起作用,或起多大的作用。

自傳記憶受損與另一個(gè)失調(diào)認(rèn)知特點(diǎn)有著密切的關(guān)聯(lián)：問題解決不足。

(4) 問題解決不足

自殺者普遍認(rèn)為生活沒有出路而選擇自殺,這種現(xiàn)象讓研究者關(guān)注問題解決與自殺行為的關(guān)系。問題解決不足體現(xiàn)在兩個(gè)方面：(1)問題解決的能力或技能不足;(2)個(gè)體對(duì)自身問題解決能力的評(píng)估水平較低。

自殺者的問題解決能力不足主要體現(xiàn)在人際方面(Williams et al.,2005),具體表現(xiàn)有：有效的問題解決策略較少(Pollock &Williams,2004;Priester &Clum,1993;Schotte &Clum,1982,1987);更關(guān)注負(fù)性結(jié)果(Schotte &Clum,1987);回避嘗試解決問題(Orbach,Bar-Joseph,&Dror,1990);對(duì)任務(wù)的反應(yīng)時(shí)更長(Kaviani,Rahimi-Darabad,&Naghavi,2005)。自殺者的問題解決能力不足并非智力或精神障礙(如：抑郁)所造成的,因此研究者認(rèn)為它是自殺者獨(dú)有的認(rèn)知特點(diǎn)(Biggam &Power,1999;Pollock &Williams,2001;Williams et al.,2005)。

有研究表明,過度概括的自傳體記憶、較差的人際問題解決與自殺之間有顯著相關(guān)(Arie,Apter,Orbach,Yefet,&Zalsman,2008)。在自傳記憶受損的作用下,自殺者提取的具體記憶較少,應(yīng)對(duì)策略相應(yīng)減少,從而出現(xiàn)問題解決困難的現(xiàn)象。并且,自殺企圖者的自傳記憶概括化程度越高,問題解決的效率越低,解決的策略數(shù)量也越少(Pollock &Williams,2001;Williams et al.,2005)。

研究還發(fā)現(xiàn),個(gè)體對(duì)自身問題解決能力的評(píng)估與自殺行為有關(guān)。個(gè)體對(duì)自己問題解決的自信程度越低,越容易產(chǎn)生絕望與自殺意念(Dixon,Heppner,&Anderson,1991;Priester &Clum,1993)。進(jìn)一步研究發(fā)現(xiàn),問題解決評(píng)估通過絕望影響自殺意念(Dixon,Heppner,&Rudd,1994)。不僅是自殺意念,較低的問題解決評(píng)估也與自殺企圖顯著相關(guān)(Rudd,Rajab,&Dahm,1994)。Gibbs等(2009)的研究以抑郁老年患者為被試,發(fā)現(xiàn)有過自殺企圖組比起非自殺企圖組,更傾向知覺整體的問題解決不足,知覺更消極。

然而,追蹤研究表明,在壓力情景下,基線水平的問題解決評(píng)估能預(yù)測兩周內(nèi)的抑郁與絕望,但不能預(yù)測自殺意念(Priester &Clum,1993)。而Grover等(2009)的研究發(fā)現(xiàn),問題解決不足能預(yù)測自殺意念,但不能預(yù)測自殺企圖。并且,問題解決可以調(diào)節(jié)壓力與自殺意念的關(guān)系,但不能調(diào)節(jié)壓力與自殺企圖。

3.3.3 心理痛苦

Shneidman(1993)提出心理痛苦(psychache)的概念,它是指一種由心理需要受阻或沒有實(shí)現(xiàn)引起的被羞辱、內(nèi)疚、憤怒、孤獨(dú)以及絕望等精神痛苦的狀態(tài)。當(dāng)這種精神痛苦的程度超過個(gè)體所能承受的最大限度,個(gè)體會(huì)將自殺視為終止這種不可承受的意識(shí)流動(dòng)的唯一方法,從而發(fā)生自殺行為。Shneidman認(rèn)為心理痛苦是引發(fā)自殺的直接原因,而其他因素,如抑郁與絕望,只有與心理痛苦相聯(lián)系才與自殺相關(guān)。

研究發(fā)現(xiàn),控制絕望和抑郁后,心理痛苦與自殺意念仍然顯著相關(guān)(Pereira,Kroner,Holden,&Flamenbaum,2010),并且相關(guān)程度高于絕望、抑郁與自殺意念的相關(guān)(Troister &Holden,2010)。還有研究表明,心理痛苦對(duì)絕望、抑郁與自殺起中介作用,是與自殺最接近的因素(DeLisle &Holden,2009)。此外,心理痛苦對(duì)社會(huì)決定完美主義與自殺的關(guān)系起完全中介作用(Flamenbaum &Holden,2007)。但是,對(duì)于自殺意念、自殺動(dòng)機(jī)及自殺準(zhǔn)備,抑郁與絕望在控制心理痛苦之后仍有顯著的貢獻(xiàn)率(Troister &Holden,2010)。因此,Shneidman的理論觀點(diǎn)并未得到完全支持。

追蹤研究表明,基線水平的心理痛苦能預(yù)測2年后的自殺意念,但抑郁與絕望不能(Troister &Holden,2012)。另一項(xiàng)研究表明,控制抑郁和絕望后,心理痛苦能預(yù)測 5個(gè)月后的自殺意念與自殺準(zhǔn)備(Troister,Davis,Lowndes,&Holden,2013)。這說明,心理痛苦與自殺可能存在因果關(guān)系。

從這些研究結(jié)果來看,心理痛苦是解釋自殺行為的重要因素,但它并非唯一因素。

3.4 小結(jié)

自殺是一個(gè)復(fù)雜的病理性行為,影響因素眾多,是生物學(xué)因素、精神障礙及心理因素共同作用的結(jié)果。以目前的研究結(jié)果來看,尚未發(fā)現(xiàn)哪個(gè)因素能完全解釋自殺行為。事實(shí)是,這些影響因素的累積及相互作用增加了自殺風(fēng)險(xiǎn)。

Joiner,Brown和 Wingate(2005)認(rèn)為自殺行為的影響因素可以分為兩大類：(1)無法抑制的沖動(dòng);(2)強(qiáng)烈的心理痛苦傾向。通過前文對(duì)自殺行為影響因素的述評(píng),可以從三個(gè)方面找到證據(jù)：其一,從生物學(xué)因素來看,血清素功能失調(diào)與自殺行為有密切的關(guān)聯(lián),但它同時(shí)也是沖動(dòng)性及抑郁癥狀的生物學(xué)基礎(chǔ);其二,從精神障礙方面來看,除了智力遲鈍、癡呆及曠野恐怖癥,幾乎所有的精神障礙都會(huì)增加自殺的風(fēng)險(xiǎn)。而精神障礙往往以沖動(dòng)控制障礙及強(qiáng)烈情緒為特征;其三,從心理因素來看,沖動(dòng)性和心理痛苦都是自殺者的心理特點(diǎn)。同時(shí),完美主義會(huì)增加個(gè)體的心理痛苦感受,而失調(diào)認(rèn)知會(huì)在沖動(dòng)和心理痛苦方面起著推波助瀾的作用。綜合來看,這三方面的影響因素相互作用,促使個(gè)體陷入難以抑制的沖動(dòng)和無法忍受的心理痛苦,最終走向自殺。

4 理論研究與證據(jù)

隨著自殺行為影響因素的研究成果不斷積累,研究者開始著眼于從系統(tǒng)的、深層次的角度理解自殺行為。自殺行為的理論模型依據(jù)一定的理論取向解釋影響因素(主要是心理因素)之間的關(guān)系,進(jìn)而剖析自殺行為的發(fā)生發(fā)展機(jī)制。

4.1 自殺差異激活理論(Differential Activation Theory of Suicidality)

自殺差異激活理論(Lau,Segal,&Williams,2004)用于解釋自殺意念及行為反復(fù)出現(xiàn)的現(xiàn)象,其理論基礎(chǔ)是 Teasdale(1988)的抑郁差異激活理論。Teasdale認(rèn)為抑郁發(fā)作期間,悲傷情緒、負(fù)性失調(diào)信念和認(rèn)知過程偏差之間建立了聯(lián)結(jié)。每一次抑郁發(fā)作時(shí),這種聯(lián)結(jié)會(huì)被強(qiáng)化并更易觸發(fā)。其結(jié)果是,很小的悲傷情緒會(huì)激活負(fù)性失調(diào)的信念,促使抑郁復(fù)發(fā)。如果被激活的內(nèi)容是全局的、負(fù)面的與自我相關(guān)的,那么抑郁就極有可能復(fù)發(fā)。而自殺意念是一種最能代表全局的、負(fù)面的與自我有關(guān)的思維模式。因此,一旦抑郁早期發(fā)作時(shí)出現(xiàn)過自殺意念或企圖,那么復(fù)發(fā)時(shí)會(huì)再次出現(xiàn)。抑郁早期發(fā)作時(shí),抑郁情緒與自殺意念形成的聯(lián)結(jié),即使抑郁恢復(fù),這種聯(lián)結(jié)仍然是潛在的。抑郁復(fù)發(fā)時(shí),自殺意念會(huì)被激活。而每次激活后,自殺意念會(huì)變得越來越容易出現(xiàn)。因此,輕微的情緒低落,或信息加工偏差都會(huì)再次引發(fā)自殺意念。

目前,有幾項(xiàng)研究支持該理論的主要觀點(diǎn)。Williams,Crane,Barnhofer,van der Does和Segal(2006)發(fā)現(xiàn)抑郁癥復(fù)發(fā)時(shí),所有的抑郁癥狀中自殺意念再次出現(xiàn)的一致性最高。這說明抑郁復(fù)發(fā)與自殺意念的再次出現(xiàn)有著密切的關(guān)聯(lián)。William等(2005)的研究表明,在情緒干擾的作用下,早期有過自殺企圖但現(xiàn)在已經(jīng)康復(fù)的被試比起從未有過自殺企圖的被試,在問題解決方面仍然表現(xiàn)更差。William,van der Does,Barnhofer,Crane和Segal(2008)另一項(xiàng)研究發(fā)現(xiàn),對(duì)于早期抑郁并有過自殺意念,但現(xiàn)在無自殺意念的被試,即使微小的情緒波動(dòng)仍能激活與絕望有關(guān)的認(rèn)知加工。Palmier-Claus,Taylor,Gooding,Dunn和Lewis(2012)的研究發(fā)現(xiàn),不穩(wěn)定的情緒能引發(fā)較高頻率與較嚴(yán)重的自殺意念。這些研究說明,抑郁早期發(fā)作時(shí),抑郁情緒、信息加工模式及自殺意念之間建立了聯(lián)結(jié)。

4.2 自殺人際理論(Interpersonal Theory of Suicide)

Joiner(2007)提出自殺人際理論,從人際關(guān)系的角度解釋自殺愿望如何發(fā)展為自殺(企圖)。該理論認(rèn)為,個(gè)體僅有自殺的愿望并不會(huì)自殺,只有同時(shí)具備實(shí)現(xiàn)愿望的能力,才會(huì)自殺,如圖1所示。

自殺愿望的產(chǎn)生來源于兩種人際狀態(tài)：累贅感(perceived burdensomeness)和未滿足的歸屬感(thwarted belongingness)。累贅感是指個(gè)體錯(cuò)誤的知覺自己的無能會(huì)給朋友、家人及社會(huì)造成負(fù)擔(dān),這種負(fù)擔(dān)的感受使個(gè)體相信自己死了比活著更有價(jià)值(Joiner et al.,2009)。未滿足的歸屬感是指個(gè)體基本的、與他人聯(lián)結(jié)的需要未獲得滿足時(shí)所產(chǎn)生的心理痛苦狀態(tài)(van Orden,Cukrowicz,Witte,&Joiner,2012)。該理論認(rèn)為,累贅感與未滿足的歸屬感會(huì)引發(fā)自殺意念的產(chǎn)生,當(dāng)二者同時(shí)存在時(shí),自殺意念達(dá)到最高水平。

圖1 自殺人際理論(van Orden et al.,2010)

自殺人際理論認(rèn)為,由于自殺威脅生存,人類天生就懼怕自殺。因此,個(gè)體要實(shí)施自殺,必須要克服恐懼與疼痛,并習(xí)得自殺能力(acquired capability for suicide),才能將自殺愿望轉(zhuǎn)變?yōu)楝F(xiàn)實(shí)。通過反復(fù)多次接觸痛苦與刺激的事件,可以降低對(duì)死亡的恐懼,并提高身體疼痛的容忍度,從而習(xí)得自殺能力。習(xí)得自殺能力的內(nèi)在機(jī)制是對(duì)痛苦、恐懼及疼痛的習(xí)慣化與拮抗作用(van Orden et al.,2010)。

自殺人際理論有兩個(gè)突出的特點(diǎn)：第一,關(guān)注自殺愿望如何轉(zhuǎn)變?yōu)楝F(xiàn)實(shí),即自殺意念變?yōu)樽詺⑵髨D;第二,從人際關(guān)系的角度理解自殺行為。實(shí)證研究有一些支持該理論(Bryan,Morrow,Anestis,&Joiner,2010;Christensen,Batterham,Soubelet,&Mackinnon,2013;Cukrowicz,Cheavens,van Orden,Ragain,&Cook,2011;Monteith,Menefee,Pettit,Leopoulos,&Vincent,2013;Smith,Cukrowicz,Poindexter,Hobson,&Cohen,2010),但也有一些不支持(Bryan,Clemans,&Hernandez,2012;Gunn,Lester,Haines,&Williams,2012;Smith,Wolford-Clevenger,Mandracchia,&Jahn,2013)。這說明該理論可能只適用一部分自殺人群,或者還有其他未考慮的重要影響因素。而且,累贅感與未滿足的歸屬感之間的關(guān)系并不十分清楚。此外,習(xí)得自殺能力是否是自殺者所必備的能力,以及該理論是否適用中國文化背景,還有待進(jìn)一步的考證。

4.3 自殺行為的認(rèn)知模型(Cognitive model of suicidal behavior)

Wenzel和 Beck(2008)整合當(dāng)前大量認(rèn)知方面的研究成果,提出自殺行為認(rèn)知模型。該模型包含三個(gè)部分：素質(zhì)易損因子、精神異常認(rèn)知過程和自殺行為認(rèn)知過程,如圖2所示。素質(zhì)易損因子是指長期存在的、類似特質(zhì)的、與精神障礙風(fēng)險(xiǎn)及自殺行為有關(guān)的因素,如：沖動(dòng)性、問題解決不足、完美主義、不良的態(tài)度和過度概括記憶。精神異常認(rèn)知過程是指與精神障礙及癥狀相關(guān)的不良認(rèn)知內(nèi)容(如：人們想什么)和信息加工偏差(如：人們?nèi)绾嗡伎?。自殺行為的認(rèn)知過程是指個(gè)體處于自殺危機(jī)時(shí)的不良認(rèn)知內(nèi)容和信息加工。

圖2 自殺行為的認(rèn)知模型(Wenzel &Beck,2008)

模型認(rèn)為,素質(zhì)易損因子通過三種方式影響自殺行為。其一,引發(fā)生活壓力,激活精神障礙的癥狀與自殺危機(jī)。其二,加劇精神障礙的認(rèn)知過程,從而觸發(fā)自殺危機(jī)。其三,削弱個(gè)體應(yīng)對(duì)的能力,并破壞自殺危機(jī)中適宜的認(rèn)知過程。素質(zhì)易損因子以一種聯(lián)合的方式激活精神異常與自殺行為的認(rèn)知過程。這不僅指多種易損因子的累積會(huì)加劇自殺行為的可能性,還說明有多種途徑在發(fā)揮作用。

個(gè)體的圖式是精神異常和自殺行為的認(rèn)知過程的基礎(chǔ),與精神干擾相聯(lián)系的圖式是使信息加工偏差的基礎(chǔ)。素質(zhì)易損因子和壓力通過激活精神異常的圖式,進(jìn)而激活自殺圖式,即自殺行為的認(rèn)知過程。

自殺圖式的激活會(huì)觸發(fā)自殺行為的認(rèn)知過程。自殺圖式至少有兩類：特質(zhì)絕望和無法忍受性,如圖3所示。無論哪個(gè)自殺圖式被激活,個(gè)體會(huì)體驗(yàn)到更多的狀態(tài)絕望。自殺圖式、狀態(tài)絕望、注意固著和選擇注意自殺線索相互作用,形成一個(gè)認(rèn)知情感漩渦,進(jìn)而產(chǎn)生自殺意念,如圖4所示。當(dāng)自殺個(gè)體處于絕望狀態(tài)時(shí),問題解決的策略會(huì)減少。因此,個(gè)體將自殺作為解決問題的策略,而不是系統(tǒng)的考慮其他的策略。個(gè)體越固著自殺是唯一的解決策略,越感到絕望,對(duì)無法忍受的知覺就越多。狀態(tài)絕望的增加會(huì)削弱個(gè)體的判斷力,強(qiáng)化“沒有出路”的信念。換句話說,狀態(tài)絕望與注意固著之間存在著雙向的作用。當(dāng)個(gè)體所能忍受的認(rèn)知情緒狀態(tài)超過閾限時(shí),自殺企圖便出現(xiàn)了。

圖3 自殺圖式與狀態(tài)絕望(Wenzel &Beck,2008)

圖4 自殺行為認(rèn)知過程(Wenzel &Beck,2008)

4.4 自殺圖式評(píng)估模型(Schematic Appraisal Mo del of Suicide,SAMS)

Johnson,Gooding和Tarrier(2008)提出自殺圖式評(píng)估模型,主要包括：負(fù)性信息加工偏差、自殺圖式和評(píng)估系統(tǒng)。

SAMS認(rèn)為負(fù)性信息加工偏差對(duì)于維持負(fù)性情緒狀態(tài)、獲取自殺相關(guān)信息起重要作用。負(fù)性信息加工偏差的結(jié)果是激活自殺圖式,并與自殺圖式一起影響評(píng)估系統(tǒng)。評(píng)估系統(tǒng)包括對(duì)現(xiàn)在、過去、未來及個(gè)人屬性的評(píng)估。自殺圖式被激活后,個(gè)體會(huì)產(chǎn)生自殺意念,認(rèn)為自殺可以逃離無法忍受的情緒或狀態(tài)。自殺圖式激活后,會(huì)抑制其他圖式,如危害較小的逃離圖式、或目標(biāo)更合適的認(rèn)知與行為。自殺圖式越強(qiáng)大、越復(fù)雜,就越能抑制其他圖式,產(chǎn)生自殺行為。實(shí)證研究表明,自殺企圖的次數(shù)越多,自殺圖式越復(fù)雜(Pratt,Gooding,Johnson,Taylor,&Tarrier,2010)。

SAMS認(rèn)為負(fù)性信息加工偏差,自殺圖式及評(píng)估系統(tǒng)相互作用產(chǎn)生了挫敗(defeat)與受困(entrapment),從而產(chǎn)生自殺行為。挫敗,是指對(duì)失敗的社會(huì)競爭、喪失及社會(huì)等級(jí)下降的感受(Gilbert &Allan,1998),可能與直接的人際沖突有關(guān),也可能與知覺到無法獲得社會(huì)資源(包括物質(zhì)資源)有關(guān)(Gilbert,2006)。受困,是指逃離當(dāng)前情境的愿望,但知覺所有的逃離路徑全被堵死(Gilbert &Allan,1998)。挫敗與受困來自評(píng)估系統(tǒng)偏差的結(jié)果。個(gè)體為了逃避無法忍受的挫敗與受困,而選擇自殺。Taylor,Gooding,Wood和Tarrier(2011)的元分析表明,挫敗、受困與自殺有著穩(wěn)定且可靠的關(guān)系。大量研究表明,挫敗與受困能解釋評(píng)估系統(tǒng)與自殺風(fēng)險(xiǎn)之間的關(guān)系,并且在控制絕望與抑郁后還能解釋較高自殺風(fēng)險(xiǎn)的變異(O’Connor,Smyth,Ferguson,Ryan,&Williams,2013;Panagioti,Gooding,&Tarrier,2012;Panagioti,Gooding,Taylor,&Tarrier,2012,2013;Taylor,Gooding,et al.,2010;Taylor,Wood,Gooding,&Tarrier,2010)。

4.5 動(dòng)機(jī)-意志整合模型(Integrated Motivational-Volitional Model of Suicidal Behaviour,IMV)

O’Connor(2011)提出動(dòng)機(jī)-意志整合模型。IMV以計(jì)劃行為理論、素質(zhì)-壓力模型及痛苦呼救模型為主要理論基礎(chǔ),整合了當(dāng)今主要自殺理論及實(shí)證研究的大量成果。IMV的大框架以計(jì)劃行為理論為基礎(chǔ),認(rèn)為自殺行為的發(fā)展有三個(gè)階段：前動(dòng)機(jī)階段、動(dòng)機(jī)階段和意志階段,如圖5所示。前動(dòng)機(jī)階段包括自殺的背景因素和扳機(jī)事件;動(dòng)機(jī)階段為行為意圖形成階段,即自殺意念與意圖的形成階段;而意志階段為意圖實(shí)施階段,即自殺意圖轉(zhuǎn)變?yōu)樽詺⑵髨D或自殺。

圖5 自殺行為的動(dòng)機(jī)-意志整合模型(O’Connor,2011)

前動(dòng)機(jī)階段是以素質(zhì)-壓力模型為基礎(chǔ)。素質(zhì)是生物的或基因的易損因素,壓力主要包括環(huán)境因素(如剝奪)及負(fù)性生活事件(如關(guān)系破裂)。

動(dòng)機(jī)階段是自殺意念和意圖的形成階段,以痛苦呼救模型為理論基礎(chǔ)。自殺意念的產(chǎn)生來自于受困,而受困由挫敗或羞恥的體驗(yàn)所引發(fā)。IMV認(rèn)為在挫敗或羞恥發(fā)展為受困的過程中,威脅自我的變量起到調(diào)節(jié)作用,如社會(huì)問題解決、應(yīng)對(duì)、記憶偏差及反芻。而受困發(fā)展為自殺意念與意圖的過程中,動(dòng)機(jī)變量起到調(diào)節(jié)作用,如：未滿足的歸屬感、累贅感、未來想法、目標(biāo)管理、主觀標(biāo)準(zhǔn)、社會(huì)支持及態(tài)度。

意志階段是行為實(shí)施階段,理論基礎(chǔ)源于計(jì)劃行為理論、痛苦呼救模型及自殺人際理論。在這一階段,自殺意念轉(zhuǎn)變?yōu)樽詺⑵髨D或自殺,意志變量起調(diào)節(jié)作用,如：自殺能力、沖動(dòng)性、實(shí)施意圖(計(jì)劃)、工具可獲得性及模仿。

總體而言,IMV以當(dāng)前的自殺理論和實(shí)證研究成果為基礎(chǔ),整合了自殺行為的病因及發(fā)展過程中的生物與心理因素。IMV將自殺看作是個(gè)體有意識(shí)計(jì)劃并實(shí)施的行為,而不是心理疾病或病理的表現(xiàn)。模型將自殺意念與自殺行為的影響因素區(qū)分開來,有助于深入理解自殺。

4.6 小結(jié)

總體而言,研究者試圖跨越生物學(xué)因素及精神障礙,從心理學(xué)的角度深層次解釋自殺行為。但不同研究者的視角略有不同。自殺差異激活理論是從抑郁癥周期復(fù)發(fā)的角度解釋自殺意念及自殺企圖重復(fù)出現(xiàn)的現(xiàn)象。自殺人際理論是從人類基本需要——?dú)w屬——的角度探討自殺意念及自殺企圖/自殺的形成機(jī)制。自殺行為的認(rèn)知模型與自殺圖式評(píng)估模型都是從認(rèn)知心理學(xué)的角度解析自殺,自殺圖式是這兩個(gè)理論的重要組成部分。但前者關(guān)注自殺圖式的內(nèi)容,而后者側(cè)重自殺圖式的結(jié)構(gòu)。從研究結(jié)果來看,以上理論都略顯片面。而動(dòng)機(jī)—意志整合模型是以計(jì)劃行為理論為基礎(chǔ),幾乎囊括了當(dāng)前所有自殺行為的理論及實(shí)證研究的成果,是一個(gè)“大”而“全”的理論模型。

可以看出,自殺理論模型的構(gòu)建由局部走向整體,由分化走向整合。分化與整合,各有利弊。分化,更細(xì)致、更深入,但缺乏全景觀。整合,更全面,但難深入,并且,整合模型涉及更多的變量,關(guān)系更復(fù)雜,容易造成研究結(jié)果難以解釋。

5 評(píng)論與研究展望

5.1 自殺行為的“過程”觀

自殺行為是眾多影響因素相互作用,不斷累積發(fā)展的結(jié)果。換句話說,自殺行為的形成不是一時(shí)的或短暫的,而是歷經(jīng)了一個(gè)過程。自殺行為是以易損特質(zhì)(如沖動(dòng)性,完美主義)為基點(diǎn),在負(fù)性認(rèn)知(如累贅感,未滿足的歸屬感)及消極情緒(如抑郁)的作用下,激活自殺圖式(如絕望),最終產(chǎn)生自殺意念與自殺企圖/自殺。自殺人際理論、自殺行為的認(rèn)知模型、自殺圖式評(píng)估模型以及動(dòng)機(jī)——意志整合模型,都體現(xiàn)出這種自殺的“過程”觀。

“過程”觀對(duì)于研究與臨床干預(yù)有指導(dǎo)意義。從研究的角度來看,“過程”觀提示研究者應(yīng)按階段來探討自殺行為形成的機(jī)制,不同階段有哪些因素,如何相互作用,一個(gè)階段在何種情況下會(huì)進(jìn)入到下一個(gè)階段。從臨床干預(yù)的角度來看,“過程”觀提示干預(yù)工作者需按照不同階段評(píng)估自殺風(fēng)險(xiǎn),有利于開展針對(duì)性的預(yù)防及干預(yù)工作。

5.2 “意念”至“行動(dòng)”的研究趨勢

自殺意念向自殺(企圖)的轉(zhuǎn)變機(jī)制是研究的發(fā)展趨勢。目前的研究大多將自殺意念、自殺企圖或自殺死亡作為因變量,較少探討自殺意念轉(zhuǎn)向自殺企圖或自殺的內(nèi)部機(jī)制。

從流行學(xué)調(diào)查結(jié)果來看,自殺意念的發(fā)生率遠(yuǎn)遠(yuǎn)高于自殺企圖,而自殺企圖的發(fā)生率又遠(yuǎn)遠(yuǎn)高于自殺死亡(Crosby et al.,2011;Nock et al.,2008)。從實(shí)證研究結(jié)果來看,有過自殺企圖的個(gè)體比僅僅只有自殺意念的個(gè)體在抑郁和絕望水平上并無較多的差異(McManama O'Brien,Becker,Spirito,Simon,&Prinstein,2014;Nock &Kazdin,2002;Taliaferro &Muehlenkamp,2014),但自殺企圖者更可能有焦慮或擾動(dòng)特征的精神障礙(如：創(chuàng)傷后應(yīng)激障礙)、較差沖動(dòng)控制(如：品行障礙與物質(zhì)濫用)(Nock et al.,2010)、更多快感缺失(Nock &Kazdin,2002)、酒精濫用(McManama O'Brien et al.,2014)、暴力及自傷(Stack,2014)。自殺死亡者與自殺企圖者在大部分抑郁癥狀上極為相似(DeJong,Overholser,&Stockmeier,2010),但自殺死亡者更有可能是男性、酒精或藥物濫用、自戀型人格障礙或身患軀體疾病(Giner et al.,2013),更有可能遭遇工作壓力及經(jīng)濟(jì)問題(DeJong et al.,2010)。這些研究結(jié)果說明,自殺意念、自殺企圖和自殺有著相似但并非完全相同的形成機(jī)制。

Klonsky和May(2014)提出用“意念”至“行動(dòng)”的框架指導(dǎo)所有自殺研究。Joiner的自殺人際理論與 O’Connor的動(dòng)機(jī)-意志整合模型在已經(jīng)進(jìn)行了一些理論探討。但仍然需要更多的研究去探討哪些自殺意念在什么條件下會(huì)轉(zhuǎn)變?yōu)樽詺⑵髨D或自殺,而哪些自殺企圖在何種條件下又會(huì)轉(zhuǎn)變?yōu)樽詺⑺劳觥?/p>

5.3 研究方向轉(zhuǎn)為機(jī)制研究

縱觀自殺行為的研究,研究者的關(guān)注點(diǎn)由哪些影響因素與自殺行為有關(guān)轉(zhuǎn)變?yōu)橛绊懸蛩厝绾螌?duì)自殺行為起作用,即研究方向轉(zhuǎn)為機(jī)制研究。實(shí)證研究發(fā)現(xiàn)了一些對(duì)自殺行為起中介或調(diào)節(jié)作用的變量,如完美主義、自傳記憶、心理痛苦、累贅感及挫敗歸屬感(見前文)。動(dòng)機(jī)——意志整合模型從理論上探討了三類調(diào)節(jié)變量：威脅自我的調(diào)節(jié)變量、動(dòng)機(jī)的調(diào)節(jié)變量和意志的調(diào)節(jié)變量,但有待更多的實(shí)證研究支持(見前文)。未來的研究可以深入探討這些變量如何相互作用對(duì)“意念”及“行為”產(chǎn)生影響,并在自殺行為發(fā)展過程中如何發(fā)揮作用。

5.4 研究方法需要突破

自殺行為研究大多采用訪談、自我報(bào)告及心理解剖的方法。盡管已經(jīng)取得一些研究成果,但仍然存在一些問題。首先,自殺是個(gè)復(fù)雜的病理性行為,而研究方法相對(duì)單一。其次,研究大多采用回溯的方式,較少采用追蹤的方法,不利于探尋變量之間的因果關(guān)系。此外,自殺行為多采用臨床心理學(xué)的研究方法,較少采用實(shí)驗(yàn)心理學(xué)。針對(duì)當(dāng)前存在問題提出幾點(diǎn)建議：(1)借助基礎(chǔ)實(shí)驗(yàn)心理學(xué)的方法了解自殺行為發(fā)展的內(nèi)在機(jī)制;(2)采用當(dāng)前新技術(shù)(如：智能手機(jī))及實(shí)時(shí)數(shù)據(jù)收集(如：生態(tài)瞬時(shí)評(píng)估)進(jìn)行追蹤研究;(3)設(shè)計(jì)更精巧的心理解剖方法,而不是籠統(tǒng)的收集信息;(4)多種研究方法綜合使用。當(dāng)然,由于自殺會(huì)危害個(gè)體生命,在研究設(shè)計(jì)中不可忽視倫理道德。

5.5 本土研究亟待開展

近10年,我國的自殺現(xiàn)狀有較大的變化,自殺率顯著下降,尤其是女性自殺率大幅度的下降,而農(nóng)村老年居民一直是自殺的高危人群。這些我國獨(dú)特的自殺現(xiàn)象該如何解釋,值得研究者思考。Wang等人(2014)認(rèn)為經(jīng)濟(jì)增長、較高的就業(yè)率及文化水平的提高等社會(huì)因素起到了關(guān)鍵作用。但這些社會(huì)變遷的因素如何轉(zhuǎn)變?yōu)榇侔l(fā)自殺行為的心理因素是值得心理學(xué)研究者探討的問題。因此,需要開展符合我國社會(huì)文化背景的自殺行為研究,這不僅能豐富我國的自殺研究成果,還能為自殺危機(jī)干預(yù)打下夯實(shí)的基礎(chǔ)。

安靜,孫啟武,郭蘭,童永勝,張亞利,李獻(xiàn)云,黃悅勤.(2012).大學(xué)新生的自殺意念與抑郁情緒、希望特質(zhì).中國心理衛(wèi)生雜志,26(8),616–619.

李獻(xiàn)云,費(fèi)立鵬,童永勝,李可進(jìn),張亞利,張艷萍,...牛雅娟.(2010).Beck自殺意念量表中文版在社區(qū)成年人群中應(yīng)用的信效度.中國心理衛(wèi)生雜志,24(4),250–255.

李獻(xiàn)云,費(fèi)立鵬,張亞利,徐東,童永勝,楊甫德,況利.(2011).Beck自殺意念量表中文版在大學(xué)學(xué)生中應(yīng)用的信效度.中國心理衛(wèi)生雜志,25(11),862–866.

梁瑛楠,楊麗珠.(2011).大學(xué)生自殺意念的流行病學(xué)特征.中國健康心理學(xué)雜志,19(8),1010–1012.

劉旺,田麗麗,陸紅.(2014).職業(yè)女性反芻思維與自殺意念的關(guān)系:希望的調(diào)節(jié)作用.中國臨床心理學(xué)雜志,22(1),119–112.

孫秀麗,栗克清,崔利軍,江琴普,高良會(huì),劉永橋,...呂華.(2010).河北省18歲及以上人群自殺未遂流行病學(xué)調(diào)查.中國心理衛(wèi)生雜志,24(5),362–365.

王文強(qiáng),丁麗君,溫程,廖震華,吳素英.(2012).廈門市18歲及以上人群自殺未遂流行病學(xué)調(diào)查.中國心理衛(wèi)生雜志,26(5),332–336.

Antypa,N.,Serretti,A.,&Rujescu,D.(2013).Serotonergic genes and suicide:A systematic review.European Neuropsychopharmacology,23(10),1125–1142.

Arie,M.,Apter,A.,Orbach,I.,Yefet,Y.,&Zalsman,G.(2008).Autobiographical memory,interpersonal problem solving,and suicidal behavior in adolescent inpatients.Comprehensive Psychiatry,49(1),22–29.

Baca-Garcia,E.,Diaz-Sastre,C.,García Resa,E.,Blasco,H.,Braquehais Conesa,D.,Oquendo,M.A.,...de Leon,J.(2005).Suicide attempts and impulsivity.European Archives of Psychiatry and Clinical Neuroscience,255(2),152–156.

Beck,A.T.,Davis,J.H.,Frederick,C.J.,Perlin,S.,Pokorny,A.D.,Schulman,R.E.,...Wittlin,B.J.(1973).Classification and nomenclature.In H.L.P.Resnick &B.C.Hathorne(Eds.),Suicide prevention in the seventies(pp.7–12).Washington,DC:U.S.Government Printing Office.

Beck,A.T.,&Steer,R.A.(1989).Clinical predictors of eventual suicide:A 5- to 10-year prospective study of suicide attempters.Journal of Affective Disorders,17(3),203–209.

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.American Journal of Psychiatry,142(5),559–563.

Beck,A.T.,Weissman,A.,Lester,D.,&Trexler,L.(1974).The measurement of pessimism:The hopelessness scale.Journal of Consulting and Clinical Psychology,42(6),861–865.

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.

Bender,T.W.,Gordon,K.H.,Bresin,K.,&Joiner,T.E.,Jr.(2011).Impulsivity and suicidality:The mediating role of painful and provocative experiences.Journal of Affective Disorders,129(1-3),301–307.

Bertolote,J.M.(2003).Suicide and mental disorders:Do we know enough?The British Journal of Psychiatry,183(5),382–383.

Biggam,F.H.,&Power,K.G.(1999).Suicidality and the state-trait debate on problem solving deficits:A re-examination with incarcerated young offenders.Archives of Suicide Research,5(1),27–42.

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.

Blasco-Fontecilla,H.,Baca-Garcia,E.,Dervic,K.,Perez-Rodriguez,M.M.,Saiz-Gonzalez,M.D.,Saiz-Ruiz,J.,...de Leon,J.(2009).Severity of personality disorders and suicide attempt.Acta psychiatrica Scandinavica,119(2),149–155.

Bortolato,M.,Pivac,N.,Muck Seler,D.,Nikolac Perkovic,M.,Pessia,M.,&Di Giovanni,G.(2013).The role of the serotonergic system at the interface of aggression and suicide.Neuroscience,236,160–185.

Bostwick,J.M.,&Pankratz,V.S.(2000).Affective disorders and suicide risk:A reexamination.American Journal of Psychiatry,157(12),1925–1932.

Bryan,C.J.,Clemans,T.A.,&Hernandez,A.M.(2012).Perceived burdensomeness,fearlessness of death,and suicidality among deployed military personnel.Personality and Individual Differences,52(3),374–379.

Bryan,C.J.,Morrow,C.E.,Anestis,M.D.,&Joiner,T.E.(2010).A preliminary test of the interpersonal-psychological theory of suicidal behavior in a military sample.Personality and Individual Differences,48(3),347–350.

Cavanagh,J.T.O.,Carson,A.J.,Sharpe,M.,&Lawrie,S.M.(2003).Psychological autopsy studies of suicide:A systematic review.Psychological Medicine,33(3),395–405.

Christensen,H.,Batterham,P.J.,Soubelet,A.,&Mackinnon,A.J.(2013).A test of the Interpersonal Theory of Suicide in a large community-based cohort.Journal of Affective Disorders,144(3),225–234.

Conner,K.R.,Bohnert,A.S.,McCarthy,J.F.,Valenstein,M.,Bossarte,R.,Ignacio,R.,...Ilgen,M.A.(2013).Mental disorder comorbidity and suicide among 2.96 million men receiving care in the Veterans Health Administration health system.Journal of Abnormal Psychology,122(1),256–263.

Crosby,A.E.,Han,B.,Ortega,L.A.G.,Parks,S.E.,&Gfroerer,J.(2011).Suicidal thoughts and behaviors among adults aged≥18 years — United States,2008–2009.Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/22012169/.

Cukrowicz,K.C.,Cheavens,J.S.,van Orden,K.A.,Ragain,R.M.,&Cook,R.L.(2011).Perceived burdensomeness and suicide ideation in older adults.Psychology and Aging,26(2),331–338.

Dahlsgaard,K.K.,Beck,A.T.,&Brown,G.K.(1998).Inadequate response to therapy as a predictor of suicide.Suicide and Life-Threatening Behavior,28(2),197–204.

Davidson,C.L.,Wingate,L.R.,Slish,M.L.,&Rasmus,K.A.(2010).The great black hope:Hope and its relation to suicide risk among African Americans.Suicide and Life-Threatening Behavior,40(2),170–180.

De Leo,D.,Burgis,S.,Bertolote,J.M.,Kerkhof,A.J.F.M.,&Bille-Brahe,U.(2006).Definitions of suicidal behavior:lessons learned from the WHO/EURO Multicentre Study.Crisis:The Journal of Crisis Intervention and Suicide Prevention,27(1),4–15.

Dean,P.J.,Range,L.M.,&Goggin,W.C.(1996).The escape theory of suicide in college students:Testing a model that includes perfectionism.Suicide and Life-Threatening Behavior,26(2),181–186.

DeJong,T.M.,Overholser,J.C.,&Stockmeier,C.A.(2010).Apples to oranges?:A direct comparison between suicide attempters and suicide completers.Journal of Affective Disorders,124(1–2),90–97.

DeLisle,M.M.,&Holden,R.R.(2009).Differentiating between depression,hopelessness,and psychache in university undergraduates.Measurement &Evaluation in Counseling &Development,42(1),46–63.

Dixon,W.A.,Heppner,P.P.,&Anderson,W.P.(1991).Problem-solving appraisal,stress,hopelessness,and suicide ideation in a college population.Journal of Counseling Psychology,38(1),51–56.

Dixon,W.A.,Heppner,P.P.,&Rudd,M.D.(1994).Problem-solving appraisal,hopelessness,and suicide ideation:Evidence for a mediational model.Journal of Counseling Psychology,41(1),91–98.

Doihara,C.,Kawanishi,C.,Ohyama,N.,Yamada,T.,Nakagawa,M.,Iwamoto,Y.,...Hirayasu,Y.(2012).Trait impulsivity in suicide attempters:Preliminary study.Psychiatry and Clinical Neurosciences,66(6),529–532.

Dougherty,D.M.,Mathias,C.W.,Marsh,D.M.,Papageorgiou,T.D.,Swann,A.C.,&Moeller,F.G.(2004).Laboratory measured behavioral impulsivity relates to suicide attempt history.Suicide and Life-Threatening Behavior,34(4),374–385.

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.Geulayov,G.,Gunnell,D.,Holmen,T.L.,&Metcalfe,C.(2012).The association of parental fatal and non-fatal suicidal behaviour with offspring suicidal behaviour and depression:A systematic review and meta-analysis.Psychological Medicine,42(8),1567–1580.

Gibbs,L.M.,Dombrovski,A.Y.,Morse,J.,Siegle,G.J.,Houck,P.R.,&Szanto,K.(2009).When the solution is part of the problem:Problem solving in elderly suicide attempters.International Journal of Geriatric Psychiatry,24(12),1396–1404.

Giegling,I.,Olgiati,P.,Hartmann,A.M.,Calati,R.,M?ller,H.J.,Rujescu,D.,&Serretti,A.(2009).Personality and attempted suicide.Analysis of anger,aggression and impulsivity.Journal of Psychiatric Research,43(16),1262–1271.

Gilbert,P.(2006).Evolution and depression:Issues and implications.Psychological Medicine,36(3),287–297.

Gilbert,P.,&Allan,S.(1998).The role of defeat and entrapment(arrested flight) in depression:an exploration of an evolutionary view.Psychological Medicine,28(3),585–598.

Giner,L.,Blasco-Fontecilla,H.,Mercedes Perez-Rodriguez,M.,Garcia-Nieto,R.,Giner,J.,Guija,J.A.,...Baca-Garcia,E.(2013).Personality disorders and health problems distinguish suicide attempters from completers in a direct comparison.Journal of Affective Disorders,151(2),474–483.

Grover,K.E.,Green,K.L.,Pettit,J.W.,Monteith,L.L.,Garza,M.J.,&Venta,A.(2009).Problem solving moderates the effects of life event stress and chronic stress on suicidal behaviors in adolescence.Journal of Clinical Psychology,65(12),1281–1290.

Gunn,J.F.,3rd,Lester,D.,Haines,J.,&Williams,C.L.(2012).Thwarted belongingness and perceived burdensomeness in suicide notes.Crisis,33(3),178–181.

Harris,E.C.,&Barralough,B.(1997).Suicide as an outcome for mental disorders.A meta-analysis.British Journal of Psychiatry,170,205–228.

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.,&Weber,C.(1994).Dimensions of perfectionism and suicide ideation.Cognitive Therapy&Research,18(5),439–460.

Johnson,J.,Gooding,P.,&Tarrier,N.(2008).Suicide risk in schizophrenia:Explanatory models and clinical implications,The Schematic Appraisal Model of Suicide(SAMS).Psychology and Psychotherapy,81(1),55–77.

Joiner,T.E.(2007).Why people die by suicide.Cambridge,MA:Harvard University Press.

Joiner,T.E.,Brown,J.S.,&Wingate,L.R.(2005).The psychology and neurobiology of suicidal behavior.Annual Review of Psychology,56,287–314.

Joiner,T.E.,van Orden,K.A.,Witte,T.K.,Selby,E.A.,Ribeiro,J.D.,Lewis,R.,&Rudd,M.D.(2009).Main predictions of the interpersonal-psychological theory of suicidal behavior:Empirical tests in two samples of young adults.Journal of Abnormal Psychology,118(3),634–646.

Kaviani,H.,Rahimi-Darabad,P.,&Naghavi,H.R.(2005).Autobiographical memory retrieval and problem-solving deficits of iranian depressed patients attempting suicide.Journal of Psychopathology and Behavioral Assessment,27(1),39–44.

Keilp,J.G.,Gorlyn,M.,Russell,M.,Oquendo,M.A.,Burke,A.K.,Harkavy-Friedman,J.,&Mann,J.J.(2013).Neuropsychological function and suicidal behavior:Attention control,memory and executive dysfunction in suicide attempt.Psychological Medicine,43(3),539–551.

Keilp,J.G.,Sackeim,H.A.,Brodsky,B.S.,Oquendo,M.A.,Malone,K.M.,&Mann,J.J.(2001).Neuropsychological dysfunction in depressed suicide attempters.American Journal of Psychiatry,158(5),735–741.

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.,&May,A.(2010).Rethinking impulsivity in suicide.Suicide and Life-Threatening Behavior,40(6),612–619.

Klonsky,E.D.,&May,A.M.(2014).Differentiating suicide attempters from suicide ideators:A critical frontier for suicidology research.Suicide and Life-Threatening Behavior,44(1),1–5.

Kokkevi,A.,Rotsika,V.,Arapaki,A.,&Richardson,C.(2012).Adolescents' self-reported suicide attempts,self-harm thoughts and their correlates across 17 European countries.Journal of Child Psychology and Psychiatry,53(4),381–389.

Lau,M.A.,Segal,Z.V.,&Williams,J.M.G.(2004).Teasdale's differential activation hypothesis:Implications for mechanisms of depressive relapse and suicidal behaviour.Behaviour Research and Therapy,42(9),1001–1017.

Leibetseder,M.M.,Rohrer,R.R.,Mackinger,H.F.,&Fartacek,R.R.(2006).Suicide attempts:Patients with and without an affective disorder show impaired autobiographical memory specificity.Cognition and Emotion,20(3-4),516–526.

Mann,J.J.(2013).The serotonergic system in mood disorders and suicidal behaviour.Philosophical Transactions of the Royal Society of London.Series B,Biological Sciences,368(1615),20120537.

Maru?i?,A.(2004).Toward a new definition of suicidality?are we prone to Fregoli's Illusion?Crisis:The Journal of Crisis Intervention and Suicide Prevention,25(4),145–146.

Marzuk,P.M.,Hartwell,N.,Leon,A.C.,&Portera,L.(2005).Executive functioning in depressed patients with suicidal ideation.Acta Psychiatrica Scandinavica,112(4),294–301.

McManama O'Brien,K.H.,Becker,S.J.,Spirito,A.,Simon,V.,&Prinstein,M.J.(2014).Differentiating adolescent suicide attempters from ideators:Examining the interaction between depression severity and alcohol use.Suicide and Life-Threatening Behavior,44(1),23–33.

McMillan,D.,Gilbody,S.,Beresford,E.,&Neilly,L.(2007).Can we predict suicide and non-fatal self-harm with the Beck Hopelessness Scale? A meta-analysis.Psychological Medicine,37(6),769–778.

Miranda,R.,Gallagher,M.,Bauchner,B.,Vaysman,R.,&Marroquin,B.(2012).Cognitive inflexibility as a prospective predictor of suicidal ideation among young adults with a suicide attempt history.Depression and Anxiety,29(3),180–186.

Miranda,R.,Valderrama,J.,Tsypes,A.,Gadol,E.,&Gallagher,M.(2013).Cognitive inflexibility and suicidal ideation:Mediating role of brooding and hopelessness.Psychiatry Research,210(1),174–181.

Monteith,L.L.,Menefee,D.S.,Pettit,J.W.,Leopoulos,W.L.,&Vincent,J.P.(2013).Examining the interpersonalpsychological theory of suicide in an inpatient veteran sample.Suicide and Life-Threatening Behavior,43(4),418–428.

Nock,M.K.,Borges,G.,Bromet,E.J.,Cha,C.B.,Kessler,R.C.,&Lee,S.(2008).Suicide and suicidal behavior.Epidemiologic Reviews,30(1),133–166.

Nock,M.K.,Hwang,I.,Sampson,N.A.,&Kessler,R.C.(2010).Mental disorders,comorbidity and suicidal behavior:Results from the national comorbidity survey replication.Molecular Psychiatry,15(8),868–876.

Nock,M.K.,&Kazdin,A.E.(2002).Examination of affective,cognitive,and behavioral factors and suicide-related outcomes in children and young adolescents.Journal of Clinical Child &Adolescent Psychology,31(1),48–58.

Nock,M.K.,&Kessler,R.C.(2006).Prevalence of and risk factors for suicide attempts versus suicide gestures:Analysis of the national comorbidity survey.Journal of Abnormal Psychology,115(3),616–623.

O'Carroll,P.W.,Berman,A.L.,Maris,R.W.,Moscicki,E.K.,Tanney,B.L.,&Silverman,M.M.(1996).Beyond the tower of babel:A nomenclature for suicidology.Suicide and Life-Threatening Behavior,26(3),237–252.

O'Connor,R.C.(2007).The relations between perfectionism and suicidality:A systematic review.Suicide and Life-Threatening Behavior,37(6),698–714.

O'Connor,R.C.,&Nock,M.K.(2014).The psychology of suicidal behaviour.The Lancet Psychiatry,1(1),73–85.

O'Keefe,V.M.,&Wingate,L.R.(2013).The role of hope and optimism in suicide risk for American Indians/Alaska Natives.Suicide and Life-Threatening Behavior,43(6),621–633.

O’Connor,R.C.(2011).Towards an integrated motivational–volitional model of suicidal behaviour.In R.C.O’Connor,S.Platt,&J.Gordon(Eds.),International handbook of suicide prevention:Research,policy and practice(pp.181–198).Chichester,United Kingdom:Wiley.

O’Connor,R.C.,Smyth,R.,Ferguson,E.,Ryan,C.,&Williams,J.M.(2013).Psychological processes and repeat suicidal behavior:A four-year prospective study.Journal of Consulting and Clinical Psychology,81(6),1137–1143.

Oquendo,M.A.,Lizardi,D.,Greenwald,S.,Weissman,M.M.,&Mann,J.J.(2004).Rates of lifetime suicide attempt and rates of lifetime major depression in different ethnic groups in the United States.Acta Psychiatrica Scandinavica,110(6),446–451.

Orbach,I.,Bar-Joseph,H.,&Dror,N.(1990).Styles of problem solving in suicidal individuals.Suicide and Life-Threatening Behavior,20(1),56–64.

Palmer,B.A.,Pankratz,V.S.,&Bostwick,J.M.(2005).The lifetime risk of suicide in schizophrenia.Archives of General Psychiatry,62(3),247–253.

Palmier-Claus,J.E.,Taylor,P.J.,Gooding,P.,Dunn,G.,&Lewis,S.W.(2012).Affective variability predicts suicidal ideation in individuals at ultra-high risk of developing psychosis:An experience sampling study.British Journal of Clinical Psychology,51(1),72–83.

Panagioti,M.,Gooding,P.A.,&Tarrier,N.(2012).Hopelessness,defeat,and entrapment in posttraumatic stress disorder:Their association with suicidal behavior and severity of depression.The Journal of Nervous and Mental Disease,200(8),676–683.

Panagioti,M.,Gooding,P.,Taylor,P.J.,&Tarrier,N.(2012).Negative self-appraisals and suicidal behavior among trauma victims experiencing PTSD symptoms:The mediating role of defeat and entrapment.Depression and Anxiety,29(3),187–194.

Panagioti,M.,Gooding,P.,Taylor,P.J.,&Tarrier,N.(2013).A model of suicidal behavior in posttraumatic stress disorder(PTSD):The mediating role of defeat and entrapment.Psychiatry Research,209(1),55–59.

Pedersen,N.L.,&Fiske,A.(2010).Genetic influences on suicide and nonfatal suicidal behavior:Twin study findings.European psychiatry,25(5),264–267.

Pereira,E.J.,Kroner,D.G.,Holden,R.R.,&Flamenbaum,R.(2010).Testing Shneidman’s model of suicidality in incarcerated offenders and in undergraduates.Personality and Individual Differences,49(8),912–917.

Phillips,M.R.,Li,X.Y.,&Zhang,Y.P.(2002).Suicide rates in China,1995–99.The Lancet,359(9309),835–840.

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.

Pollock,L.R.,&Williams,J.M.G.(2004).Problem-solving in suicide attempters.Psychological Medicine,34(1),163–167.

Pompili,M.,Girardi,P.,Ruberto,A.,&Tatarelli,R.(2005).Suicide in borderline personality disorder:A meta-analysis.Nordic Journal of Psychiatry,59(5),319–324.

Pratt,D.,Gooding,P.,Johnson,J.,Taylor,P.,&Tarrier,N.(2010).Suicide schemas in non-affective psychosis:An empirical investigation.Behaviour Research and Therapy,48(12),1211–1220.

Priester,M.J.,&Clum,G.A.(1993).The problem-solving diathesis in depression,hopelessness,and suicide ideation:A longitudinal analysis.Journal of Psychopathology and Behavioral Assessment,15(3),239–253.

Qin,P.(2011).The impact of psychiatric illness on suicide:Differences by diagnosis of disorders and by sex and age of subjects.Journal of Psychiatric Research,45(11),1445–1452.

Rasmussen,S.A.,Elliott,M.A.,&O'Connor,R.C.(2012).Psychological distress and perfectionism in recent suicide attempters:The role of behavioural inhibition and activation.Personality and Individual Differences,52(6),680–685.

Rasmussen,S.A.,O'Connor,R.C.,&Brodie,D.(2008).The role of perfectionism and autobiographical memory in a sample of parasuicide patients:an exploratory study.Crisis:The Journal of Crisis Intervention and Suicide Prevention,29(2),64–72.

Rihmer,Z.(2011).Depression and suicidal behaviour.In R.C.O’Connor,S.Platt,&J.Gordon(Eds.),International handbook of suicide prevention:Research,policy and practice(pp.59–73).Chichester,United Kingdom:Wiley.

Rubin,D.C.(2005).A basic-systems approach to autobiographical memory.Current Directions in Psychological Science,14(2),79–83.

Rudd,M.D.,Rajab,M.H.,&Dahm,P.F.(1994).Problemsolving appraisal in suicide ideators and attempters.American Journal of Orthopsychiatry,64(1),136–149.

Schotte,D.E.,&Clum,G.A.(1982).Suicide ideation in a college population:A test of a model.Journal of Consulting and Clinical Psychology,50(5),690–696.

Schotte,D.E.,&Clum,G.A.(1987).Problem-solving skills in suicidal psychiatric patients.Journal of Consulting and Clinical Psychology,155(1),49–54.

Shahar,G.,Bareket,L.,Rudd,M.D.,&Joiner,T.E.(2006).In severely suicidal young adults,hopelessness,depressive symptoms,and suicidal ideation constitute a single syndrome.Psychological Medicine,36(7),913–922.

Shneidman,E.S.(1993).Suicide as psychache.Journal of Nervous and Mental Disease,18(3),147–149.

Silverman,M.M.(2006).The language of suicidology.Suicide and Life-Threatening Behavior,36(5),519–532.

Silverman,M.M.,Berman,A.L.,Sanddal,N.D.,O'Carroll,P.W.,&Joiner,T.E.(2007).Rebuilding the tower of babel:A revised nomenclature for the study of suicide and suicidal behaviors part 1:Background,rationale,and methodology.Suicide and Life-Threatening Behavior,37(3),248–263.

Slama,F.,Merle,S.,Ursulet,G.,Charles-Nicolas,A.,&Ballon,N.(2011).Prevalence of and risk factors for lifetime suicide attempts among Caribbean people in the French West Indies.Psychiatry Research,190(2–3),271–274.

Smith,P.N.,Cukrowicz,K.C.,Poindexter,E.K.,Hobson,V.,&Cohen,L.M.(2010).The acquired capability for suicide:A comparison of suicide attempters,suicide ideators,and non-suicidal controls.Depression and Anxiety,27(9),871–877.

Smith,P.N.,Wolford-Clevenger,C.,Mandracchia,J.T.,&Jahn,D.R.(2013).An exploratory factor analysis of the acquired capability for suicide scale in male prison inmates.Psychological Services,10(1),97–105.

Snyder,C.R.(1995).Conceptualizing,measuring,and nurturing hope.Journal of Counseling &Development,73(3),355–360.

Snyder,C.R.,Harris,C.,Anderson,J.R.,Holleran,S.A.,Irving,L.M.,Sigmon,S.T.,...Harney,P.(1991).The will and the ways:Development and validation of an individual-differences measure of hope.Journal of Personality and Social Psychology,60(4),570–585.

Sokero,P.,Eerola,M.,Rytsala,H.,Melartin,T.,Leskela,U.,Lestel?-Mielonen,P.,&Isomets?,E.(2006).Decline in suicidal ideation among patients with MDD is preceded by decline in depression and hopelessness.Journal of Affective Disorders,95(1-3),95–102.

Stack,S.(2014).Differentiating suicide ideators from attempters:Violence—a research note.Suicide and Life-Threatening Behavior,44(1),46–57.

Suokas,J.T.,Per?l?,J.,Suominen,K.,Saarni,S.,L?nnqvist,J.,&Suvisaari,J.M.(2010).Epidemiology of suicide attempts among persons with psychotic disorder in the general population.Schizophrenia Research,124(1–3),22–28.

Suominen,K.,Isomets?,E.,Ostamo,A.,&L?nnqvist,J.(2004).Level of suicidal intent predicts overall mortality and suicide after attempted suicide:A 12-year follow-up study.BMC Psychiatry,4,11.

Swann,A.C.,Dougherty,D.M.,Pazzaglia,P.J.,Pham,M.,Steinberg,J.L.,&Moeller,F.G.(2005).Increased impulsivity associated with severity of suicide attempt history in patients with bipolar disorder.American Journal of Psychiatry 162(9),1680–1687.

Taliaferro,L.A.,&Muehlenkamp,J.J.(2014).Risk and protective factors that distinguish adolescents who attempt suicide from those who only consider suicide in the past year.Suicide and Life-Threatening Behavior,44(1),6-22.

Taylor,P.J.,Gooding,P.A.,Wood,A.M.,Johnson,J.,Pratt,D.,&Tarrier,N.(2010).Defeat and entrapment in schizophrenia:The relationship with suicidal ideation and positive psychotic symptoms.Psychiatry Research,178(2),244–248.

Taylor,P.J.,Gooding,P.,Wood,A.M.,&Tarrier,N.(2011).The role of defeat and entrapment in depression,anxiety,and suicide.Psychological Bulletin,137(3),391–420.

Taylor,P.J.,Wood,A.M.,Gooding,P.,&Tarrier,N.(2010).Appraisals and suicidality:The mediating role of defeat and entrapment.Archives of Suicide Research,14(3),236–247.

Teasdale,J.D.(1988).Cognitive vulnerability to persistent depression.Cognition &Emotion,2(3),247–274.

Troister,T.,Davis,M.P.,Lowndes,A.,&Holden,R.R.(2013).A five-month longitudinal study of psychache and suicide ideation:Replication in general and high-risk university students.Suicide and Life-Threatening Behavior,43(6),611–620.

Troister,T.,&Holden,R.R.(2010).Comparing psychache,depression,and hopelessness in their associations with suicidality:A test of Shneidman’s theory of suicide.Personality and Individual Differences,49(7),689–693.

Troister,T.,&Holden,R.R.(2012).A two-year prospective study of psychache and its relationship to suicidality among high-risk undergraduates.Journal of Clinical Psychology,68(9),1019–1027.

Tucker,R.P.,Wingate,L.R.,O’Keefe,V.M.,Mills,A.C.,Rasmussen,K.,Davidson,C.L.,&Grant,D.M.(2013).Rumination and suicidal ideation:The moderating roles of hope and optimism.Personality and Individual Differences,55(5),606–611.

van Heeringen,K.,&Mann,J.J.(2014).The neurobiology of suicide.The Lancet Psychiatry,1(1),63–72.

van Orden,K.A.,Cukrowicz,K.C.,Witte,T.K.,&Joiner,T.E.(2012).Thwarted belongingness and perceived burdensomeness:Construct validity and psychometric properties of the Interpersonal Needs Questionnaire.Psychological Assessment,24(1),197–215.

van Orden,K.A.,Witte,T.K.,Cukrowicz,K.C.,Braithwaite,S.R.,Selby,E.A.,&Joiner,T.E.(2010).The Interpersonal theory of suicide.Psychological Review,117(2),575–600.

Wang,C.W.,Chan,C.L.W.,&Yip,P.S.F.(2014).Suicide rates in China from 2002 to 2011:An update.Social Psychiatry and Psychiatric Epidemiology,49(6),929–941.

Wang,K.T.,Wong,Y.J.,&Fu,C.-C.(2013).Moderation effects of perfectionism and discrimination on interpersonal factors and suicide ideation.Journal of Counseling Psychology,60(3),367–378.

Wenzel,A.,&Beck,A.T.(2008).A cognitive model of suicidal behavior:Theory and treatment.Applied and Preventive Psychology,12(4),189–201.

Wenzel,A.,Brown,G.K.,&Beck,A.T.(2009).Cognitive Therapy for Suicida Patients:Scientific and Clinical Applications.Washington,DC:American Psychological Association.

WHO.(2014).Preventing suicide:a global imperativeWorld Health Organization(Ed.).Retrieved from http://apps.who.int/iris/bitstream/10665/131056/1/9789241564779_eng.pd f?ua=1

Williams,J.M.G.,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.

Williams,J.M.G.,Barnhofer,T.,Crane,C.,Hermans,D.,Raes,F.,Watkins,E.,&Dalgleish,T.(2007).Autobiographical memory specificity and emotional disorder.Psychological Bulletin,133(1),122–148.

Williams,J.M.G.,&Broadbent,K.(1986).Autobiographical memory in suicide attempters.Journal of Abnormal Psychology,95(2),144–149.

Williams,J.M.G.,Crane,C.,Barnhofer,T.,van der Does,A.J.,&Segal,Z.V.(2006).Recurrence of suicidal ideation across depressive episodes.Journal of Affective Disorders,91(2-3),189–194.

Williams,J.M.G.,&Dritschel,B.H.(1988).Emotional disturbance and the specificity of autobiographical memory.Cognition &Emotion,2(3),221–234.

Williams,J.M.G.,van der Does,A.J.W.,Barnhofer,T.,Crane,C.,&Segal,Z.S.(2008).Cognitive reactivity,suicidal ideation and future fluency:Preliminary investigation of a differential activation theory of hopelessness/suicidality.Cognitive Therapy and Research,32(1),83–104.

Witte,T.K.,Merrill,K.A.,Stellrecht,N.E.,Bernert,R.A.,Hollar,D.L.,Schatschneider,C.,&Joiner,T.E.(2008)."Impulsive" youth suicide attempters are not necessarily all that impulsive.Journal of Affective Disorders,107(1-3),107–116.

Wyder,M.,&De Leo,D.(2007).Behind impulsive suicide attempts:Indications from a community study.Journal of Affective Disorders,104(1-3),167–173.

Young,M.A.,Fogg,L.F.,Scheftner,W.,Fawcett,J.,Akiskal,H.,&Maser,J.(1996).Stable trait components of hopelessness:Baseline and sensitivity to depression.Journal of Abnormal Psychology,105(2),155–165.