Social behavior, interaction appraisals, and suicidal ideation in schizophrenia: The dangers of being alone

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Abstract

Despite the increasing attention to social appraisals in suicide risk, the interpersonal correlates of suicidal thoughts and behavior in schizophrenia are not well understood. Ecological momentary assessment could reveal whether dysfunctional social appraisals and behavior are evident in people with schizophrenia with suicidal ideation. A total of 93 outpatients with diagnoses of schizophrenia with (n = 18, 19%) and without (N = 75; 81%) suicidal ideation participated in one week of intensive daily monitoring via mobile devices, generating real-time reports on the quantity of social interactions and appraisals about them, as well as information concerning concurrent affect and symptoms. The presence of suicidal ideation was not associated with the quantity of social interactions or time spent alone, but it was associated with the anticipation of being alone as well as greater negative and lower positive affect when alone. Despite this aversive experience of being alone, people with suicidal ideation reported negative appraisals about the value of recent and potential social interactions. These findings suggest that suicidal ideation in schizophrenia may not be associated with the quantity of social interactions, but with negative expectations about the quality of social interactions coupled with an aversive experience of being alone. Cognitive therapy interventions that address negative expectations and pleasure about social interactions, especially when alone, may reduce suicidal ideation.

Introduction

Approximately 5–10% of people with schizophrenia die by suicide and 40–60% attempt suicide (Chapman et al., 2015, Fialko et al., 2006, Hawton et al., 2005, Radomsky et al., 1999). Risk factors for suicidal ideation and behavior in people with schizophrenia include demographic (e.g. younger age, higher level of education) and symptoms (e.g., active psychotic symptoms, depressive symptoms; Palmier-Claus et al., 2014, Popovic et al., 2014), and suicidal ideation has been observed to be a strong predictor of suicidal behavior (Skodlar et al., 2008). Unfortunately, as noted by multiple authors (Laursen et al., 2014, Nock et al., 2008), these risk factors provide limited understanding of the mechanisms of suicidal thoughts in schizophrenia.

In the broader literature, interpersonal stressors (compared to non-social stressors) appear to be more associated with risk for suicide (Liu and Miller, 2014) and social appraisals are central to emerging theories of suicide. For example, theories of suicidal behavior feature perceived alienation from other people (e.g., “thwarted belongingness” (Van Orden et al., 2010), perceived lack of availability of others to provide rescue from distress (Taylor et al., 2010), and perception of others as a source of threat (Selten and Cantor-Graae, 2005). Psychological models of suicide specifically adapted for schizophrenia (e.g., the Schematic Appraisal Model of Suicide) implicate perceptions of low social standing and alienation from others (Johnson et al., 2008) It is not fully clear why social factors are particularly associated with suicide compared to non-social factors, although translational research indicates that perceived lack of close relationships violates fundamental drives across species and produces a cascade of neurobiological changes (Cacioppo et al., 2015).

Social appraisals in schizophrenia, including aberrant beliefs regarding the intentions of others (Savla et al., 2013) might intersect with suicidal thoughts in ways unique from people without schizophrenia. The negative effects of social isolation appear to be explained by diminished reward from social interactions and perceived threat (Cacioppo et al., 2015). Some prior work has indicated that more severe paranoia, including perceptions of potential threat from others, is associated with higher likelihood of subsequent suicidal thoughts (Palmier-Claus et al., 2014). On the other hand, negative symptoms, which include social disinterest and withdrawal, have been found to be unrelated or perhaps even protective against suicidal ideation and behavior (Fenton, 2000, Hawton et al., 2005). The distinction between reward systems pertaining to “wanting” and “liking” (Berridge et al., 2009) can be applied to understanding the experience of social interactions or being alone. People with the diagnosis of schizophrenia experience diminished “wanting” or anticipation of social interactions, despite relatively intact “liking” or consummatory pleasure from social interactions (Gard et al., 2007). On the one hand, theories of suicide, including in schizophrenia, generally posit distress related to disconnection from others. On the other hand, people with social anhedonia (although not necessarily people with schizophrenia (Gard et al., 2014)) experience greater positive affect and lower negative affect when alone (Brown et al., 2007, Kwapil et al., 2009). Thus, the experience of being alone versus with others may vary in schizophrenia depending upon whether suicidal ideation is present.

Ecological momentary assessment (EMA), or the repeated naturalistic sampling of daily experiences, offers a potentially useful method for examining social behavior and appraisals in relation to suicidal thoughts. The differential impact of social context on affect and symptoms has been examined with EMA; for example, people higher in social anhedonia spend more time alone and report greater positive affect and less negative affect when alone (Brown et al., 2007, Kwapil et al., 2009). Although prior studies have examined affective predictors of moment-by-moment suicidal ideation in schizophrenia (Palmier-Claus et al., 2014), to our knowledge, studies have not yet employed EMA in contrasting quantity and appraisals of social interactions among people with and without suicidal thoughts.

We examined the social behavior and social interaction appraisals of outpatients with diagnosed schizophrenia who were experiencing suicidal ideation compared to people not endorsing suicidal thoughts using EMA. We predicted that people with suicidal ideation would experience lower positive affect and greater negative affect when alone and in the absence of recent social interactions, consistent with the role of perceived social disconnection in recent theories of suicidal thoughts (Taylor et al., 2010, Van Orden et al., 2010). Additionally, we predicted that people with suicidal ideation would experience greater perceived social threat (paranoia, suspiciousness) during social interactions and greater negative appraisals of social interactions in general. Lastly, we explored the quantity of social interactions and we examined the role of current depressive symptoms (excluding measurement of suicidal ideation) and delusional ideation in order to determine the specificity of effects of suicidal ideation versus more general depressive and psychotic symptoms.

Section snippets

Sample

The data from this study derived from baseline evaluation of participants (N = 126) in an ongoing parent study that focuses on implementation of Cognitive Behavioral Social Skills Training (CBSST) in Assertive Community Treatment (ACT) teams (Granholm et al., 2015). All participants were enrolled in ACT teams in the San Diego County Adult and Older Adult Mental Health System. To enroll in ACT programs, participants must have a severe and persistent mental illness and be at risk for

Sample characteristics (Table 1)

Participants were on average, middle-aged, mostly male, unmarried and with a high school level of education. There were no sociodemographic differences between the group with suicidal ideation (n = 18) compared to the group without (n = 75). The group with suicidal ideation had more severe depressive symptoms on the BDI-2 (sans the suicide item) and more severe psychiatric symptoms on the BPRS. The rates of endorsement of BDI suicide items for the entire sample were as follows (no ideation: 71%,

Discussion

This is the first study, to our knowledge, to employ EMA to investigate the frequency, social appraisals, and concurrent affective experience in social interactions among people with schizophrenia recently experiencing suicidal thoughts. Our findings suggest two potentially important misperceptions about social interactions. First, people with suicidal ideation were approximately 50% more likely to predict being alone in the near future, yet they spent an equivalent amount of time with others

Role of the funding source

This study was supported by National Institutes of Health grants MH091057, MH100417, and MH107260.

Contributors

All of the authors contributed to the interpretation of results and production of the manuscript. EG, JS and JH developed the measures and implemented data collection and measures. CD led development of the hypotheses and conducted statistical analyses. RM and DP contributed to the production of results and interpretation.

Conflicts of interest

Dr. Granholm reported consulting fees from Otsuka America Pharmaceutical, Inc. None of the authors has any conflicts of interest to report.

Acknowledgment

The authors would like to thank Rebecca Daly for her role in data management

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