Exploring the nature of social relationships and self-injurious thoughts and behaviours

Background: Suicide is a major public health concern, with the World Health Organization estimating that approximately 703, 000 people die by suicide every year worldwide. Interventions for mental health support and suicide prevention have shifted focus in recent years, to promote more community-based strategies in addition to individual interventions. Furthermore, the role of interpersonal factors (e.g., loneliness, perfectionism, trauma) on mental health and suicide risk has received increasing recognition by both government agencies and the general public in light of the restrictions that were introduced during the COVID-19 pandemic. These social restrictions have been shown to be associated with strained relationships and have highlighted the role loneliness, family support, social support and social connections can have on mental health. Aims: The current series of studies, underpinned by theories including the Integrated Motivational-Volitional (IMV) model, aimed to explore the relationship between loneliness and self-injurious thoughts and/or behaviour within the context of other interpersonal factors and established drivers of suicide risk. To achieve this aim, the current thesis addressed three overarching research questions: 1) with a particular focus on loneliness, which interpersonal factors are associated with risk of self-injurious thoughts and behaviours?; 2) which interpersonal factors differentiate between those who have a history of self-injurious behaviours, history of self-injurious thoughts only, and no history of self-injurious thoughts or behaviours?; 3) what does an in-depth exploration reveal about the role of loneliness in relation to self-injurious thoughts and behaviour? Methods: A range of research and analytical methods were employed to address the research questions. Firstly, a systematic review and meta-analysis (Chapter 2) was conducted to explore the association between loneliness and later self-injurious thoughts and behaviour (SIB). Socio-demographic characteristics (age, gender, geographic location) and depression were also investigated to identify what role, if any, they may have in the association between loneliness and SIB. The findings of the review informed the subsequent quantitative and qualitative studies. Using an anonymous cross-sectional online survey reported in Chapter 3, 400 participants were recruited to explore where loneliness might fit within the context of the IMV model. In Chapter 4, Interpretative Phenomenological Analysis was used to explore the role of interpersonal factors prior to a suicide attempt in ten participants with lived experience. The findings of these studies led to the third and final study. This study quantitatively explored different forms of loneliness, as well as parental attachment, in the association with SIB (Chapter 5; n=582 participants). The final study also explored whether depression mediated between different forms of loneliness and suicidal ideation. Results: The meta-analysis (n=33 studies) confirmed a significant, prospective relationship between loneliness and both self-injurious thoughts and self-injurious behaviours. Furthermore, it indicated that depression was a significant mediator between loneliness and later SIB (n=8 studies). Narratively (n=38 studies), there was evidence to suggest that a significant association between loneliness and later SIB was likely to be identified between ten weeks and five years after baseline in those aged 13-22 or ≥54 years old, or among those based in Europe. Empirical findings in Chapter 3 revealed that within the context of the IMV model, loneliness was likely to operate as a motivational moderator; moderating the association between entrapment and suicidal ideation. It also distinguished between those with no history of self-injurious thoughts and behaviours and those with any history of SIB. Loneliness was also found to significantly moderate between childhood emotional abuse and suicidal ideation, and partially mediate between all childhood traumas investigated and suicidal ideation and between socially prescribed perfectionism and suicidal ideation. Findings from Chapter 4 indicated that participants experienced different forms of loneliness prior to suicide attempt, specifically social isolation, lack of emotional connectedness and lack of feeling understood. Further superordinate themes included unique patterns of social support, emotional secrecy, personality traits and social transition. These qualitative findings guided the aims of the final study. To this end, in Chapter 5, four forms of loneliness (family, romantic, social and global) were explored in detail, with the analysis revealing that each operated as a motivational moderator (within the IMV model) when all other forms of loneliness were controlled for. Additionally, stress mediated between socially prescribed perfectionism and all forms of loneliness, with a full mediating effect evident between perfectionism and romantic loneliness. In turn, depression independently mediated between family, global and romantic loneliness in relation to suicidal ideation though this mediating effect of depression between romantic loneliness and suicidal ideation was significantly smaller than the other effects. Conclusion: Three research questions were addressed in this thesis. Loneliness was a significant predictor of later SIB (addressing question 1) and distinguished those with a history of self-harm ideation from those with no history of self-harm ideation or behaviour (question 2). Childhood emotional abuse, socially supported coping, socially prescribed perfectionism, depression and suicidal ideation were also found to be associated with SIB (questions 1 & 2). Loneliness was found to be a particular risk factor for later SIB in specific demographic populations, with further findings suggesting romantic loneliness may be the most pernicious of all forms of loneliness (question 3). These findings add to the body of evidence that loneliness is not synonymous with social isolation. Furthermore, loneliness must be recognised as a multi-dimensional risk factor for SIB. Romantic loneliness may pose a particular risk to wellbeing, especially for those with high traits of socially prescribed perfectionism. Strategies to reduce SIB may benefit from focusing on a range of interpersonal factors across the life-course (e.g., reducing the occurrence/effects of childhood trauma) and social support. This thesis offers evidence that loneliness, especially romantic loneliness, is a significant predictor of SIB which warrants further investigation of known at-risk groups

Suicide risk in personality disorders: a systematic review

Purpose of review: This systematic review aimed to distil recent literature investigating psychosocial factors which may account for the association between personality disorder (PD) and suicide attempt or suicide death. Recent findings: Suicide risk is particularly elevated in people with PD compared to those with no, or many other, mental health diagnoses. Despite this, suicide prevention strategies for PD populations have not progressed markedly in recent years. It is critical, therefore, to identify additional factors associated with suicide in PD populations. Summary: Of the 34 studies included in this review, most identified a relationship between personality disorder and suicide attempt and/or death. Historical interpersonal factors (e.g., childhood trauma), drug and alcohol use, and ideation-to-enaction factors were commonly associated with suicide-related outcomes. Interventions that provide interpersonal support may reduce suicide attempts. Limitations of the review include the heterogeneity of studies and small sample sizes

Loneliness as a predictor of suicidal ideation and behaviour: a systematic review and meta-analysis of prospective studies

Background: Suicide and suicidal behaviour are global health concerns with complex aetiologies. Given the recent research and policy focus on loneliness, this systematic review aimed to determine the extent to which loneliness predicts suicidal ideation and/or behaviour (SIB) over time. Methods: A keyword search of five major databases (CINHAL, Medline, PsychArticles, PsychInfo and Web of Knowledge) was conducted. Papers for inclusion were limited to those using a prospective longitudinal design, written in English and which measured loneliness at baseline and SIB at a later time-point. Results: After duplicates were removed, 947 original potential papers were identified, with 22 studies meeting the review criteria. Meta-analysis revealed loneliness was a significant predictor of both suicidal ideation and behaviour and there was evidence that depression acted as a mediator. Furthermore, studies which consisted of predominantly female participants were more likely to report a significant relationship, as were studies where participants were aged 16-20 or >55 years at baseline. Limitations: There was considerable variability in measures, samples and methodologies used across the studies. Middle-aged adults were under-represented, as were individuals from minority ethnic backgrounds. All studies were conducted in countries where self-reliance and independence (i.e. individualism) are the cultural norm. Conclusions: Loneliness predicts later SIB in select populations. However, due to the heterogeneity of the studies further research is needed to draw more robust conclusions. Suicide death also needs to be included as an outcome measure. A focus on more collectivist countries is also required