# Mediation effect of anxious attachment on relationship between childhood trauma and suicidal ideation sensitive to psychological pain levels

H. Ihme, Philippe Courtet, Nathan Risch, Jonathan Dubois, R. Belzeaux,
Émilie Olié

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## To cite this version:

H. Ihme, Philippe Courtet, Nathan Risch, Jonathan Dubois, R. Belzeaux, et al. Mediation effect of anxious attachment on relationship between childhood trauma and suicidal ideation sensitive to psychological pain levels. European Psychiatry, 2023, 66 (1), pp.e79. 10.1192/j.eurpsy.2023.2452. hal-04220283

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Research Article

**Cite this article:** Ihme H, Courtet P, Risch N, Dubois J, Belzeaux R, Olié E (2023). Mediation effect of anxious attachment on relationship between childhood trauma and suicidal ideation sensitive to psychological pain levels.
*European Psychiatry*, **66**(1), e79, 1–9
https://doi.org/10.1192/j.eurpsy.2023.2452

Received: 04 July 2023

Revised: 06 September 2023

Accepted: 06 September 2023

**Keywords:**

attachment; childhood trauma; depression; psychological pain; social pain; suicidal ideation

**Corresponding author:**

Raoul Belzeaux;

Email: raoul.belzeaux@gmail.com

# Mediation effect of anxious attachment on relationship between childhood trauma and suicidal ideation sensitive to psychological pain levels

Hannah Ihme<fnref n="1" /> ID, Philippe Courtet²,³ ID, Nathan Risch² ID, Jonathan Dubois²,³ ID,
Raoul Belzeaux<fnref n="1" />,⁴ and Emilie Olié²,³ ID

## Abstract

**Background.** Childhood trauma (CT), depression, and psychological pain are known predictors of suicidal ideation. Recent literature additionally highlights the importance of the attachment system.

**Methods.** We aimed to predict suicidal ideation through CT, attachment, and psychological and social pain by using mediation models aiming to predict suicidal ideation through CT (mediator) and attachment (mediator). In the same models, we introduced psychological or social pain as a moderator of the relationship between attachment, CT, and suicidal ideation. We included 161 depressed patients and assessed depression, attachment, CT, suicidal ideation, psychological pain, and social pain.

**Results.** We found (1) a complete mediating effect of anxious attachment ($a_2b_2 = 0.0035$, $CI_{95\%} = [0.0010; 0.0069]$) on the relationship between CT on suicidal ideation, and (2) a significant complete conditional mediating effect of anxious attachment and psychological pain (index of moderated mediation VAS: $0.0014; CI_{95\%} = [0.0002; 0.0032]$) but not social pain on the relationship between CT and suicidal ideation. Both models were controlled for history of suicidal attempt, depression severity, and sex.

**Conclusions.** Our results suggest a developmental profile of suicidal ideation in mood disorder that is characterized by the presence of CT and insecure attachment, especially anxious attachment, that is sensitive to experiences of psychological pain. Nevertheless, we cannot conclude that avoidantly attached individuals do not present the same mechanism, as they may not disclose those ideas.

## Introduction

Suicidal ideation is a preceding risk factor for suicide attempts [1, 2] and death [3]. The presence of suicidal thoughts is common in mood disorders, with a prevalence ranging from 47 to 69% [4, 5], and has a critical impact on prognosis. Consequently, it seems important to understand which factors, such as environmental stressors or trait-dependent variables, are involved in the genesis of suicidal ideation [6, 7]. Recent literature has focused on the importance of childhood trauma (CT) [1, 8, 9] and the neurobehavioral attachment system [10–14] in the suicidal process.

The attachment system is one of the neurobehavioral systems that affect the functioning of the whole organism throughout life, especially in interpersonal stressful situations. Its expression in adulthood is shaped by early interactions with the primary caregiver in childhood [15, 16] and therefore marked by the occurrence of CT. CT is defined as any act or series of acts done or omitted by any person 5 years older than the child that result in harm, potential harm, or imminent danger to the child [17, 18]. Cognitive affective schemata acquired during these early periods of life serve as the basis for interpreting interpersonal relationships later on and thus guide perception, thoughts, and actions [19–21]. A secure attachment is thought to be the result of a responsive and caring environment [22], and is expressed through trust in oneself and others, as well as an inner sense of security. The experience of repetitive frightening and frustrating experiences as typical for CT is linked to an insecure attachment characterized by fear and/or avoidance, mistrust, hopelessness, and pessimism [23, 24].

Avoidant attachment expresses in excessive self-reliance and low interpersonal intimacy. Avoidantly attached individuals tend to deactivate their attachment system in times of stress through suppressing and inhibiting support-seeking tendencies [15]. Anxiously attached individuals in line with a strong desire for closeness tend towards hyperactivation strategies,

<footnote n="1">¹Institut de Neurosciences de la Timone, UMR 7289, Aix Marseille Université, CNRS, Marseille, France; ²IGF, Univ. Montpellier, CNRS, INSERM, Montpellier, France; ³Department of Emergency Psychiatry and Acute Care, Lapeyronie Hospital, CHU Montpellier, Montpellier, France and ⁴Pôle Universitaire de Psychiatrie, CHU de Montpellier, Montpellier, France</footnote>
Research Article

**Cite this article:** Ihme H, Courtet P, Risch N, Dubois J, Belzeaux R, Olié E (2023). Mediation effect of anxious attachment on relationship between childhood trauma and suicidal ideation sensitive to psychological pain levels.
*European Psychiatry*, **66**(1), e79, 1–9
https://doi.org/10.1192/j.eurpsy.2023.2452

Received: 04 July 2023

Revised: 06 September 2023

Accepted: 06 September 2023

**Keywords:**

attachment; childhood trauma; depression; psychological pain; social pain; suicidal ideation

**Corresponding author:**

Raoul Belzeaux;

Email: raoul.belzeaux@gmail.com

# Mediation effect of anxious attachment on relationship between childhood trauma and suicidal ideation sensitive to psychological pain levels

Hannah Ihme<fnref n="1" /> ID, Philippe Courtet²,³ ID, Nathan Risch² ID, Jonathan Dubois²,³ ID,
Raoul Belzeaux<fnref n="1" />,⁴ and Emilie Olié²,³ ID

## Abstract

**Background.** Childhood trauma (CT), depression, and psychological pain are known predictors of suicidal ideation. Recent literature additionally highlights the importance of the attachment system.

**Methods.** We aimed to predict suicidal ideation through CT, attachment, and psychological and social pain by using mediation models aiming to predict suicidal ideation through CT (mediator) and attachment (mediator). In the same models, we introduced psychological or social pain as a moderator of the relationship between attachment, CT, and suicidal ideation. We included 161 depressed patients and assessed depression, attachment, CT, suicidal ideation, psychological pain, and social pain.

**Results.** We found (1) a complete mediating effect of anxious attachment ($a_2b_2 = 0.0035$, $CI_{95\%} = [0.0010; 0.0069]$) on the relationship between CT on suicidal ideation, and (2) a significant complete conditional mediating effect of anxious attachment and psychological pain (index of moderated mediation VAS: $0.0014; CI_{95\%} = [0.0002; 0.0032]$) but not social pain on the relationship between CT and suicidal ideation. Both models were controlled for history of suicidal attempt, depression severity, and sex.

**Conclusions.** Our results suggest a developmental profile of suicidal ideation in mood disorder that is characterized by the presence of CT and insecure attachment, especially anxious attachment, that is sensitive to experiences of psychological pain. Nevertheless, we cannot conclude that avoidantly attached individuals do not present the same mechanism, as they may not disclose those ideas.

## Introduction

Suicidal ideation is a preceding risk factor for suicide attempts [1, 2] and death [3]. The presence of suicidal thoughts is common in mood disorders, with a prevalence ranging from 47 to 69% [4, 5], and has a critical impact on prognosis. Consequently, it seems important to understand which factors, such as environmental stressors or trait-dependent variables, are involved in the genesis of suicidal ideation [6, 7]. Recent literature has focused on the importance of childhood trauma (CT) [1, 8, 9] and the neurobehavioral attachment system [10–14] in the suicidal process.

The attachment system is one of the neurobehavioral systems that affect the functioning of the whole organism throughout life, especially in interpersonal stressful situations. Its expression in adulthood is shaped by early interactions with the primary caregiver in childhood [15, 16] and therefore marked by the occurrence of CT. CT is defined as any act or series of acts done or omitted by any person 5 years older than the child that result in harm, potential harm, or imminent danger to the child [17, 18]. Cognitive affective schemata acquired during these early periods of life serve as the basis for interpreting interpersonal relationships later on and thus guide perception, thoughts, and actions [19–21]. A secure attachment is thought to be the result of a responsive and caring environment [22], and is expressed through trust in oneself and others, as well as an inner sense of security. The experience of repetitive frightening and frustrating experiences as typical for CT is linked to an insecure attachment characterized by fear and/or avoidance, mistrust, hopelessness, and pessimism [23, 24].

Avoidant attachment expresses in excessive self-reliance and low interpersonal intimacy. Avoidantly attached individuals tend to deactivate their attachment system in times of stress through suppressing and inhibiting support-seeking tendencies [15]. Anxiously attached individuals in line with a strong desire for closeness tend towards hyperactivation strategies,

<footnote n="1">¹Institut de Neurosciences de la Timone, UMR 7289, Aix Marseille Université, CNRS, Marseille, France; ²IGF, Univ. Montpellier, CNRS, INSERM, Montpellier, France; ³Department of Emergency Psychiatry and Acute Care, Lapeyronie Hospital, CHU Montpellier, Montpellier, France and ⁴Pôle Universitaire de Psychiatrie, CHU de Montpellier, Montpellier, France</footnote>
for example, control, force, or intrusion in order to evoke attention or love from attachment figures [25, 26]. Both attachment strategies might prove insufficient in the face of extremely painful experiences such as loss or exclusion [43] and are effectively linked to higher vulnerability to suicidal ideation [27, 28].

In general, painful experiences (entrapment, isolation) and the associated affective state, psychological pain, are thought to be a central trigger of suicidal ideation [7, 29–32]. Psychological pain refers to an interplay of feelings of shame, guilt, humiliation, dread, fear of “losing oneself,” inner emptiness, confusion, emotional flooding, and social phenomena such as withdrawal or freezing [31–35]. Levels of psychological pain are higher in subjects who present suicidal ideation than in those who do not [36]; and predict suicidal behavior in depressed patients even when controlled for depression severity [37, 38]. Furthermore, suicidal ideation can also be triggered by social pain, the affect experienced at separation and exclusion [39, 40]. Depending on the definition, expected exclusion [41] or merely actual exclusion [42] may be included. While psychological pain can be understood as a “broader construct” incorporating feelings of numbing, humiliation, and coping behavior [35] and must not be tied to the social domain, social pain is distinguishable from psychological pain because it occurs in the social context [42]. As dread of separation is a key component of the attachment system, it has been hypothesized that especially social pain leads to an attachment crisis, in which all coping strategies (distancing as well as approaching) fail, and which then turns to a suicidal crisis [43]. In contrast to psychological pain, social pain can be ethically induced in an experimental setting [44].

Recent literature has already linked CT, insecure attachment, suicidal ideation, and psychological pain in nonclinical settings. In a cohort of 371 Iranian colleague students, CT influenced suicidal ideation directly but also mediated through psychological pain [45]. In 2,259 Chinese students, a mediating effect of psychological pain on the relationship between emotional abuse and suicidal ideation was found [46]. Likewise in a clinical setting, Martins et al. [47] report a direct effect of CT on suicidal ideation in 102 subjects with substance abuse disorder. This effect, however, vanished when the capacity to manage psychological pain was introduced as mediator. Introducing attachment as mediator, Musetti et al. [12] showed a mediating effect of anxious attachment on the effect of traumatic life events on suicidal ideation in a cohort of 950 Italian adults. However, in a clinical population another study failed to show a mediating effect of attachment but found a direct effect of emotional abuse on current suicidal ideation in 96 mood disorder patients [48].

## Objectives

To the best of our knowledge, no study so far has investigated all four concepts, CT, attachment, psychological or social pain, and suicidal ideation. We hypothesize that developmental profiles presenting CT and insecure attachment lead to higher expression of suicidal ideation in mood disorder patients and that this vulnerability is intensified as a function of the experienced intensity of psychological or social pain. We suppose that both types of pain activate deep-rooted attachment-related cognitive schemata and trigger aforementioned attachment strategies [49]. Therefore we introduce social and psychological pain as a moderator, considering it as a trigger for the attachment system [49] and especially its

potential to lead to an attachment crisis and subsequently a suicidal crisis [31, 43]. We formulate the following hypotheses:

H1: The relationship between CT and suicidal ideation is mediated by attachment:

1.1. Insecure attachment (anxious and avoidant) reinforces the effect of CT on suicidal ideation.

1.2. Secure attachment has a buffering effect on suicidal ideation.

H2: Psychological pain has a conditional mediating effect on the mediation of CT, attachment, and suicidal ideation, with a mediating effect of attachment sensitive to the level of experienced psychological pain.

H3: Social pain has conditional mediating effect on the mediation of CT, attachment, and suicidal ideation, with a mediating effect of attachment sensitive to the level of experienced social pain.

## Methods

### Participants and setting

We analyzed retrospective data from 161 depressed inpatients recruited in the Academic Hospital of Montpellier, France. Patients were classified into three groups based on their history of suicide attempts: 43 of them had attempted in the last 8 days (recently), 52 had attempted suicide at least once in their life (previously), and 66 never attempted suicide (never). General inclusion criteria were current MDE and age of majority. Patients engaging in substance abuse within the last 6 months, current (hypo)manic or mixed episode, lifetime schizo-affective disorder and/or schizophrenia as well as chronic neurologic pathology were excluded. Due to the primary objective of physical pain, patients on tricyclics or NSSRI were excluded due to possible analgesic effects. Six patients were excluded due to missing data. The inclusion period of the study was from June 2015 to May 2021. A trained and experienced clinician assessed psychopathology using the Mini International Neuro-psychiatric Interview (MINI 5.00) and the Structured Clinical Interview for DSM-IV Axis II Disorders (SCID II) for borderline personality disorder.

### Questionnaire data

#### Childhood trauma

CT was assessed in retrospective by the French version of the short Childhood Trauma Questionnaire-Short Form (CTQ-SF; 28 items) [17, 50]. For the CTQ, patients rate the frequency of abusive and neglectful behavior on a 5-point Likert-Scale ranging from 1 (“never true”) to 5 (“very often true”). Items can either be added up to a total trauma score or be grouped into five subtypes of maltreatment: emotional, physical, and sexual abuse and physical and emotional neglect. Physical abuse refers to the intentional harming of the child through physical violence; sexual abuse refers to any sexualised contact between an adult and the child regardless of whether it is done with the child's consent; and finally, psychological, or emotional abuse refers to any act or speech of demeaning, humiliating or intimidating character from caregiver to child. Physical neglect, on the other hand, refers to domestic situations in which the child's basic physical needs for food, shelter, clothing, safety, and health care are not met, while emotional neglect refers to caregivers' failure to meet the child's basic emotional and psychological needs for love, encouragement, and support. The total trauma score ranges from 25 to 125 and scores
for example, control, force, or intrusion in order to evoke attention or love from attachment figures [25, 26]. Both attachment strategies might prove insufficient in the face of extremely painful experiences such as loss or exclusion [43] and are effectively linked to higher vulnerability to suicidal ideation [27, 28].

In general, painful experiences (entrapment, isolation) and the associated affective state, psychological pain, are thought to be a central trigger of suicidal ideation [7, 29–32]. Psychological pain refers to an interplay of feelings of shame, guilt, humiliation, dread, fear of “losing oneself,” inner emptiness, confusion, emotional flooding, and social phenomena such as withdrawal or freezing [31–35]. Levels of psychological pain are higher in subjects who present suicidal ideation than in those who do not [36]; and predict suicidal behavior in depressed patients even when controlled for depression severity [37, 38]. Furthermore, suicidal ideation can also be triggered by social pain, the affect experienced at separation and exclusion [39, 40]. Depending on the definition, expected exclusion [41] or merely actual exclusion [42] may be included. While psychological pain can be understood as a “broader construct” incorporating feelings of numbing, humiliation, and coping behavior [35] and must not be tied to the social domain, social pain is distinguishable from psychological pain because it occurs in the social context [42]. As dread of separation is a key component of the attachment system, it has been hypothesized that especially social pain leads to an attachment crisis, in which all coping strategies (distancing as well as approaching) fail, and which then turns to a suicidal crisis [43]. In contrast to psychological pain, social pain can be ethically induced in an experimental setting [44].

Recent literature has already linked CT, insecure attachment, suicidal ideation, and psychological pain in nonclinical settings. In a cohort of 371 Iranian colleague students, CT influenced suicidal ideation directly but also mediated through psychological pain [45]. In 2,259 Chinese students, a mediating effect of psychological pain on the relationship between emotional abuse and suicidal ideation was found [46]. Likewise in a clinical setting, Martins et al. [47] report a direct effect of CT on suicidal ideation in 102 subjects with substance abuse disorder. This effect, however, vanished when the capacity to manage psychological pain was introduced as mediator. Introducing attachment as mediator, Musetti et al. [12] showed a mediating effect of anxious attachment on the effect of traumatic life events on suicidal ideation in a cohort of 950 Italian adults. However, in a clinical population another study failed to show a mediating effect of attachment but found a direct effect of emotional abuse on current suicidal ideation in 96 mood disorder patients [48].

## Objectives

To the best of our knowledge, no study so far has investigated all four concepts, CT, attachment, psychological or social pain, and suicidal ideation. We hypothesize that developmental profiles presenting CT and insecure attachment lead to higher expression of suicidal ideation in mood disorder patients and that this vulnerability is intensified as a function of the experienced intensity of psychological or social pain. We suppose that both types of pain activate deep-rooted attachment-related cognitive schemata and trigger aforementioned attachment strategies [49]. Therefore we introduce social and psychological pain as a moderator, considering it as a trigger for the attachment system [49] and especially its

potential to lead to an attachment crisis and subsequently a suicidal crisis [31, 43]. We formulate the following hypotheses:

H1: The relationship between CT and suicidal ideation is mediated by attachment:

1.1. Insecure attachment (anxious and avoidant) reinforces the effect of CT on suicidal ideation.

1.2. Secure attachment has a buffering effect on suicidal ideation.

H2: Psychological pain has a conditional mediating effect on the mediation of CT, attachment, and suicidal ideation, with a mediating effect of attachment sensitive to the level of experienced psychological pain.

H3: Social pain has conditional mediating effect on the mediation of CT, attachment, and suicidal ideation, with a mediating effect of attachment sensitive to the level of experienced social pain.

## Methods

### Participants and setting

We analyzed retrospective data from 161 depressed inpatients recruited in the Academic Hospital of Montpellier, France. Patients were classified into three groups based on their history of suicide attempts: 43 of them had attempted in the last 8 days (recently), 52 had attempted suicide at least once in their life (previously), and 66 never attempted suicide (never). General inclusion criteria were current MDE and age of majority. Patients engaging in substance abuse within the last 6 months, current (hypo)manic or mixed episode, lifetime schizo-affective disorder and/or schizophrenia as well as chronic neurologic pathology were excluded. Due to the primary objective of physical pain, patients on tricyclics or NSSRI were excluded due to possible analgesic effects. Six patients were excluded due to missing data. The inclusion period of the study was from June 2015 to May 2021. A trained and experienced clinician assessed psychopathology using the Mini International Neuro-psychiatric Interview (MINI 5.00) and the Structured Clinical Interview for DSM-IV Axis II Disorders (SCID II) for borderline personality disorder.

### Questionnaire data

#### Childhood trauma

CT was assessed in retrospective by the French version of the short Childhood Trauma Questionnaire-Short Form (CTQ-SF; 28 items) [17, 50]. For the CTQ, patients rate the frequency of abusive and neglectful behavior on a 5-point Likert-Scale ranging from 1 (“never true”) to 5 (“very often true”). Items can either be added up to a total trauma score or be grouped into five subtypes of maltreatment: emotional, physical, and sexual abuse and physical and emotional neglect. Physical abuse refers to the intentional harming of the child through physical violence; sexual abuse refers to any sexualised contact between an adult and the child regardless of whether it is done with the child’s consent; and finally, psychological, or emotional abuse refers to any act or speech of demeaning, humiliating or intimidating character from caregiver to child. Physical neglect, on the other hand, refers to domestic situations in which the child’s basic physical needs for food, shelter, clothing, safety, and health care are not met, while emotional neglect refers to caregivers’ failure to meet the child’s basic emotional and psychological needs for love, encouragement, and support. The total trauma score ranges from 25 to 125 and scores
for each maltreatment type range from 5 to 25. The scale is widely used; internal consistency ranges from 0.70 to 0.90 and retest reliability from 0.66 to 0.94.

## Attachment

Attachment was measured by the French version of the Relationship Scales Questionnaire (RSQ) [51, 52]. The RSQ contains 30 items, that load on three factors: avoidance (7 items, e.g. "I find it hard to depend on other people."), anxiety (5 items, e.g. "I worry that I will be hurt if I allow myself to become too close to others."), and security (5 items, e.g. "I find it easy to get emotionally close to others."). Those factors build subdimensions, and for each subdimension, sum scores can be calculated by adding up respective items see results of the factorial analyses in Guédeney et al., 2010). Patients respond on a 5-point Likert scale: (1) *Not at all like me*, (3) *Somewhat like me*, and (5) *Very much like me*. The factor structure of the RSQ demonstrates good psychometric qualities: moderate internal consistency (Cronbach α 0.66 for avoidance factor, 0.69 for anxiety factor, and 0.60 for security factor) and good interrater reliability (intraclass correlation avoidance factor-ICC = 0.80; anxiety factor-ICC = 0.85; security factor-ICC = 0.78). Patients living alone without partner were asked to respond either for their last relationship experience or for their typical behavior in close relationships.

## Suicidal ideation

We measured suicidal ideation by the suicidal item of the French version of the Beck Depression Inventory – second edition [53] that reads as follows: (0) *I do not have any thoughts of killing myself*. (1) *I have thoughts of killing myself, but I would not carry them out*. (2) *I would like to kill myself*. (3) *I would like to kill myself if I had the chance*. Patients were asked to choose the response that best described their suicidal ideation status. A previous study showed that a single suicide item from a depression rating scale is a valid approach to assess SI compared with the Scale for Suicide Ideation [54]. This method was previously used in large clinical studies, such as the STAR*D [55] or more recent studies [54, 56, 57].

## Depression severity

Depression severity was measured by the clinician-rated Inventory for Depressive Symptomatology (IDS-C) [58]. The IDS-C asks the clinician to evaluate the patient's typical depressive symptoms on 30 items regarding the symptom severity during the last 7 days (e.g. item 6 – *Mood (Irritability)*: (0) *Does not feel irritable*. (1) *Feels irritable less than half the time*. (2) *Feels irritable more than half the time*. (3) *Feels extremely irritable virtually all the time*). The sum score provides information about symptom severity. The English version shows good internal consistency (Cronbach's α = 0.88) and high external validity ($r_{HRSD} = 0.92, r_{BDI} = 0.61$).

## Psychological pain

Psychological pain was evaluated by a visual analog scale, PPP-VAS [37]. Resembling the scales commonly used in the assessment of physical pain [59], PPP-VAS is a well-established tool to measure psychological pain in suicidal cohorts [38]. By means of the PPP-VAS current, mean, and worst psychological pain can be evaluated. Worst psychological pain predicted significantly suicidal events in a prior study [38], therefore we only included worst psychological pain in our statistical analysis. Participants rated the worst intensity of psychological pain during the last 2 weeks on a scale from 0 (none) to 10 (maximum possible pain).

## Social pain

Social pain was assessed by the Need-Threat Scale (NTS) after the subjects played the Cyberball game. The Cyberball game is a validated paradigm of social exclusion during which participants are instructed that they would play with two other players an online ball game. But instead, they play with a preset computer program and are given a cover story to ensure that they believe the other players are human. The Cyberball game comprised 50 throws with two successive conditions. In the first condition, participants played with the other two players and received the ball as many times as the virtual players (1/3 of the throws). In the second condition, participants were excluded by the two other players during the 20 last throws. Successively, participants filled out the NTS. The NTS assesses 20 subjectively experienced consequences of being excluded during the game, including ratings of self-esteem ("I felt liked"), belongingness ("I felt rejected"), meaningfulness ("I felt invisible"), and control ("I felt powerful"), on a scale ranging from 1 = "not at all" to 5 = "very much". To create the score of social pain, the total score was reverse-coded (100 – total score). The score ranges between 0 and 80. The higher the score was, the more intense was the perception of social exclusion and social pain.

## Statistical analysis

First, we calculated the Spearman's Rho correlation coefficients to display shared variance between the metric variables that we wanted to include in the mediation analyses, namely CT, attachment, suicidal ideation, depression, and psychological and social pain.

Then, we calculated multiple mediation analyses. In the first models, we tested the H1, the mediation effect of attachment on the relationship between CT and suicidal ideation by employing the SPSS Macro PROCESS Version 3.5 by Hayes [60], model 4. PROCESS operates on the principle of ordinary least square regressions; confidence intervals and interference statistic are calculated through bootstrapping with 5000 samples.

Second, the hypothesized moderated mediation models (H2 and H3) were tested in separate models using a bootstrapping approach to assess the significance of the indirect effects at differing levels of the moderator [60]. CT served as the predictor variable, with the three factors of attachment as parallel mediators. As in the simple mediation analysis, the outcome variable was suicidal ideation, additionally here, the level of psychological pain and social pain was the proposed moderator. The term conditional indirect effect refers to the fact that path coefficients – effects of the mediator to the outcome variable (b) and the direct effect of the predictor CT on the outcome suicidal ideation (c') depend on a moderator (shown in Figures 2 and 3). Statistically those coefficients are expressed as a function of the moderator variable and are therefore reported by inserting model values for the moderator. PROCESS calculates the *b* coefficients automatically by inserting 3 values for m: one value marking the 16th (low), 50th (medium), and 64th (high) percentile respectively. Concerning the interference statistic, an *index of moderated mediation* was used to test the significance of the moderated mediation, that is, the difference of the indirect effects across levels of psychological and social pain [60]. The models were calculated using the SPSS Macro PROCESS Version 4.1 by Hayes [60], model 15, with bias-corrected 95% confidence intervals using bootstrapping with 5,000 samples. Significant effects are supported by the absence of zero within the confidence intervals.
for each maltreatment type range from 5 to 25. The scale is widely used; internal consistency ranges from 0.70 to 0.90 and retest reliability from 0.66 to 0.94.

## Attachment

Attachment was measured by the French version of the Relationship Scales Questionnaire (RSQ) [51, 52]. The RSQ contains 30 items, that load on three factors: avoidance (7 items, e.g. "I find it hard to depend on other people."), anxiety (5 items, e.g. "I worry that I will be hurt if I allow myself to become too close to others."), and security (5 items, e.g. "I find it easy to get emotionally close to others."). Those factors build subdimensions, and for each subdimension, sum scores can be calculated by adding up respective items see results of the factorial analyses in Guédeney et al., 2010). Patients respond on a 5-point Likert scale: (1) *Not at all like me*, (3) *Somewhat like me*, and (5) *Very much like me*. The factor structure of the RSQ demonstrates good psychometric qualities: moderate internal consistency (Cronbach α 0.66 for avoidance factor, 0.69 for anxiety factor, and 0.60 for security factor) and good interrater reliability (intraclass correlation avoidance factor-ICC = 0.80; anxiety factor-ICC = 0.85; security factor-ICC = 0.78). Patients living alone without partner were asked to respond either for their last relationship experience or for their typical behavior in close relationships.

## Suicidal ideation

We measured suicidal ideation by the suicidal item of the French version of the Beck Depression Inventory – second edition [53] that reads as follows: (0) *I do not have any thoughts of killing myself*. (1) *I have thoughts of killing myself, but I would not carry them out*. (2) *I would like to kill myself*. (3) *I would like to kill myself if I had the chance*. Patients were asked to choose the response that best described their suicidal ideation status. A previous study showed that a single suicide item from a depression rating scale is a valid approach to assess SI compared with the Scale for Suicide Ideation [54]. This method was previously used in large clinical studies, such as the STAR*D [55] or more recent studies [54, 56, 57].

## Depression severity

Depression severity was measured by the clinician-rated Inventory for Depressive Symptomatology (IDS-C) [58]. The IDS-C asks the clinician to evaluate the patient's typical depressive symptoms on 30 items regarding the symptom severity during the last 7 days (e.g. item 6 – *Mood (Irritability)*: (0) *Does not feel irritable*. (1) *Feels irritable less than half the time*. (2) *Feels irritable more than half the time*. (3) *Feels extremely irritable virtually all the time*). The sum score provides information about symptom severity. The English version shows good internal consistency (Cronbach's α = 0.88) and high external validity ($r_{HRSD} = 0.92, r_{BDI} = 0.61$).

## Psychological pain

Psychological pain was evaluated by a visual analog scale, PPP-VAS [37]. Resembling the scales commonly used in the assessment of physical pain [59], PPP-VAS is a well-established tool to measure psychological pain in suicidal cohorts [38]. By means of the PPP-VAS current, mean, and worst psychological pain can be evaluated. Worst psychological pain predicted significantly suicidal events in a prior study [38], therefore we only included worst psychological pain in our statistical analysis. Participants rated the worst intensity of psychological pain during the last 2 weeks on a scale from 0 (none) to 10 (maximum possible pain).

## Social pain

Social pain was assessed by the Need-Threat Scale (NTS) after the subjects played the Cyberball game. The Cyberball game is a validated paradigm of social exclusion during which participants are instructed that they would play with two other players an online ball game. But instead, they play with a preset computer program and are given a cover story to ensure that they believe the other players are human. The Cyberball game comprised 50 throws with two successive conditions. In the first condition, participants played with the other two players and received the ball as many times as the virtual players (1/3 of the throws). In the second condition, participants were excluded by the two other players during the 20 last throws. Successively, participants filled out the NTS. The NTS assesses 20 subjectively experienced consequences of being excluded during the game, including ratings of self-esteem ("I felt liked"), belongingness ("I felt rejected"), meaningfulness ("I felt invisible"), and control ("I felt powerful"), on a scale ranging from 1 = "not at all" to 5 = "very much". To create the score of social pain, the total score was reverse-coded (100 – total score). The score ranges between 0 and 80. The higher the score was, the more intense was the perception of social exclusion and social pain.

## Statistical analysis

First, we calculated the Spearman's Rho correlation coefficients to display shared variance between the metric variables that we wanted to include in the mediation analyses, namely CT, attachment, suicidal ideation, depression, and psychological and social pain.

Then, we calculated multiple mediation analyses. In the first models, we tested the H1, the mediation effect of attachment on the relationship between CT and suicidal ideation by employing the SPSS Macro PROCESS Version 3.5 by Hayes [60], model 4. PROCESS operates on the principle of ordinary least square regressions; confidence intervals and interference statistic are calculated through bootstrapping with 5000 samples.

Second, the hypothesized moderated mediation models (H2 and H3) were tested in separate models using a bootstrapping approach to assess the significance of the indirect effects at differing levels of the moderator [60]. CT served as the predictor variable, with the three factors of attachment as parallel mediators. As in the simple mediation analysis, the outcome variable was suicidal ideation, additionally here, the level of psychological pain and social pain was the proposed moderator. The term conditional indirect effect refers to the fact that path coefficients – effects of the mediator to the outcome variable (b) and the direct effect of the predictor CT on the outcome suicidal ideation (c') depend on a moderator (shown in Figures 2 and 3). Statistically those coefficients are expressed as a function of the moderator variable and are therefore reported by inserting model values for the moderator. PROCESS calculates the *b* coefficients automatically by inserting 3 values for m: one value marking the 16th (low), 50th (medium), and 64th (high) percentile respectively. Concerning the interference statistic, an *index of moderated mediation* was used to test the significance of the moderated mediation, that is, the difference of the indirect effects across levels of psychological and social pain [60]. The models were calculated using the SPSS Macro PROCESS Version 4.1 by Hayes [60], model 15, with bias-corrected 95% confidence intervals using bootstrapping with 5,000 samples. Significant effects are supported by the absence of zero within the confidence intervals.
For all models, we corrected the standard errors for heteroscedasticity [61], and report unstandardized regression coefficients. Effects were controlled for the severity of depression, the history of suicide attempt (recently, previously, never), and sex, which were included as covariates. In two separate models, we additionally added borderline personality disorder as binary variable as covariate. We calculated models for the CTQ total score and all CT subtypes, but only display in detail the results for CTQ total score in the paper.

## Results

### Description of the cohort

Our cohort was predominantly female (72.5%), single (65.2%), depressed (66.5%), and had a high school diploma (73.3%). 66.5% of patients were diagnosed with a unipolar, 33.5% with a bipolar depression. 23% of the patients were diagnosed with borderline personality disorder. Sociodemographic and clinical characteristics of the cohort are shown in Table 1.

Correlation coefficients can be found in Figure 1. Values of the trauma subtypes were highly correlated with each other, security factor presented a mediocre negative correlation with the avoidance factor social pain, and a positive correlation with the anxiety factor of attachment. Further, attachment anxiety was mediocrevly correlated to the avoidance factor, the total trauma score, physical neglect, emotional abuse and neglect, and suicidal ideation. Suicidal ideation was mediocrevly correlated to psychological pain, depression, total trauma score, and emotional abuse. Last, social pain was mediocrevly positively correlated to emotional abuse and the total trauma score, and negatively to the security factor of attachment.

### Mediation analyses

#### H1: Mediation effect of anxious attachment on relationship between CT and suicidal ideation

The first mediation analysis conducted using ordinary least squares path analysis showed that CT (total trauma score) had a complete mediated effect through anxious attachment factor on suicidal ideation $a_2b_2 = 0.0035$, $CI_{95\%} = [0.0010; 0.0069]$. We found neither a direct nor an indirect effect for the avoidant or secure attachment factor (shown in Figure 2). In a second analysis, we calculated the same model for all subtypes of CT and found the same complete indirect effect of anxious attachment factor for emotional abuse and neglect, and physical abuse (shown in Supplementary material).

#### H2: Moderated mediation effect of anxious attachment on relationship between CT and suicidal ideation, with psychological pain as moderator

Next, we tested the hypothesized moderated mediation model, in which psychological pain moderates the effect of path *b* (shown in Figure 3). Higher CT was associated with higher attachment anxiety, $a_2 = 0.0576$, SE = 0.0186, *p* = 0.003. Psychological pain was found to moderate the effect of anxious attachment and suicidal ideation (Unstandardised interaction = 0.0238, SE = .0105, t = 2.2646, *p* = 0.0250). We found a moderate mediation effect of psychological pain on the relationship between CT, attachment anxiety, and suicidal ideation (index of moderated mediation = 0.0014, $CI_{95\%} = [0.0002;0.0032]$). This indicates that individuals with a developmental profile of CT and anxious attachment reported higher suicidal ideation the higher they reported psychological pain levels. The conditional indirect effect

<table><caption>**Table 1.** Description of socio-demographic and clinical characteristics of the whole sample (n = 161)</caption><thead><tr><th>Sociodemographic variables</th><th>n</th><th>%</th></tr></thead><tbody><tr><td>Age μ (SD)</td><td>37.63</td><td>(14.46)</td></tr><tr><td>Females</td><td>117</td><td>72.5</td></tr><tr><td>Civil status</td><td></td><td></td></tr><tr><td>Single</td><td>105</td><td>65.2</td></tr><tr><td>In relationship</td><td>56</td><td>34.8</td></tr><tr><td>Education</td><td></td><td></td></tr><tr><td>No high school diploma</td><td>43</td><td>26.7</td></tr><tr><td>High school diploma or more</td><td>118</td><td>73.3</td></tr><tr><td>Borderline personality disorder</td><td>38</td><td>23.5</td></tr><tr><td>Bipolar disorder</td><td>54</td><td>33.5</td></tr><tr><td>History of suicide attempts</td><td></td><td></td></tr><tr><td>Recently (&lt;8 days)</td><td>43</td><td>26.7</td></tr><tr><td>Previously (&gt;1 month)</td><td>52</td><td>32.3</td></tr><tr><td>Never</td><td>66</td><td>41.0</td></tr><tr><td>Self-rating questionnaires</td><td>μ (SD)</td><td></td></tr><tr><td>BDI total score minus suicidal item</td><td>18.17</td><td>(6.85)</td></tr><tr><td>BDI – suicidal ideation (item G)</td><td>1.06</td><td>(1.02)</td></tr><tr><td>NTS – total social pain score</td><td>53.86</td><td>(12.0)</td></tr><tr><td>PPP-VAS – worst psychological pain during the last 14 days</td><td>8.75</td><td>(1.75)</td></tr><tr><td>CTQ – total trauma score</td><td>49.61</td><td>(18.78)</td></tr><tr><td>CTQ – physical abuse</td><td>8.24</td><td>(4.74)</td></tr><tr><td>CTQ – emotional neglect</td><td>13.58</td><td>(5.21)</td></tr><tr><td>CTQ – physical neglect</td><td>8.19</td><td>(3.61)</td></tr><tr><td>CTQ – sexual abuse</td><td>7.07</td><td>(3.66)</td></tr><tr><td>CTQ – emotional abuse</td><td>12.54</td><td>(6.25)</td></tr><tr><td>RSQ – factor avoidance</td><td>21.48</td><td>(4.72)</td></tr><tr><td>RSQ – factor anxiety</td><td>15.39</td><td>(4.56)</td></tr><tr><td>RSQ – factor security</td><td>17.08</td><td>(3.88)</td></tr><tr><td>Clinician-rated questionnaire</td><td></td><td></td></tr><tr><td>IDS-C – total depression score</td><td>38.53</td><td>(8.70)</td></tr></tbody></table>

Abbreviations: BDI, Beck depression inventory; CTQ, childhood trauma questionnaire; IDS-C, clinician-rated Inventory for depressive symptomatology; PPP-VAS, physical psychological pain visual analogical scale; RSQ, relationship scale questionnaire.

was strongest in those reporting the highest psychological pain (64th percentile; effect = 0.0046, SE = 0.0020, 95% CI = [0.0013; 0.0090]) and did not reach significance in those reporting the lowest psychological pain (16th percentile, effect = 0.0019, SE = 0.0013, 95% CI = [-0.0003; 0.0048]). Psychological pain moderated the effect of attachment avoidance on suicidal ideation (Unstandardised interaction = -0.0232, SE = .0111, t = -2.0864, *p* = .0387). However, there was no indication of moderated mediation of psychological pain on the effect of CT over avoidance and security factor on suicidal ideation. Similar results were obtained for separated models of moderated mediation with emotional abuse and neglect, and physical abuse as predictors (shown in Figure 3, and Supplementary material).
For all models, we corrected the standard errors for heteroscedasticity [61], and report unstandardized regression coefficients. Effects were controlled for the severity of depression, the history of suicide attempt (recently, previously, never), and sex, which were included as covariates. In two separate models, we additionally added borderline personality disorder as binary variable as covariate. We calculated models for the CTQ total score and all CT subtypes, but only display in detail the results for CTQ total score in the paper.

## Results

### Description of the cohort

Our cohort was predominantly female (72.5%), single (65.2%), depressed (66.5%), and had a high school diploma (73.3%). 66.5% of patients were diagnosed with a unipolar, 33.5% with a bipolar depression. 23% of the patients were diagnosed with borderline personality disorder. Sociodemographic and clinical characteristics of the cohort are shown in Table 1.

Correlation coefficients can be found in Figure 1. Values of the trauma subtypes were highly correlated with each other, security factor presented a mediocre negative correlation with the avoidance factor social pain, and a positive correlation with the anxiety factor of attachment. Further, attachment anxiety was mediocrevly correlated to the avoidance factor, the total trauma score, physical neglect, emotional abuse and neglect, and suicidal ideation. Suicidal ideation was mediocrevly correlated to psychological pain, depression, total trauma score, and emotional abuse. Last, social pain was mediocrevly positively correlated to emotional abuse and the total trauma score, and negatively to the security factor of attachment.

### Mediation analyses

#### H1: Mediation effect of anxious attachment on relationship between CT and suicidal ideation

The first mediation analysis conducted using ordinary least squares path analysis showed that CT (total trauma score) had a complete mediated effect through anxious attachment factor on suicidal ideation $a_2b_2 = 0.0035$, $CI_{95\%} = [0.0010; 0.0069]$. We found neither a direct nor an indirect effect for the avoidant or secure attachment factor (shown in Figure 2). In a second analysis, we calculated the same model for all subtypes of CT and found the same complete indirect effect of anxious attachment factor for emotional abuse and neglect, and physical abuse (shown in Supplementary material).

#### H2: Moderated mediation effect of anxious attachment on relationship between CT and suicidal ideation, with psychological pain as moderator

Next, we tested the hypothesized moderated mediation model, in which psychological pain moderates the effect of path *b* (shown in Figure 3). Higher CT was associated with higher attachment anxiety, $a_2 = 0.0576$, SE = 0.0186, *p* = 0.003. Psychological pain was found to moderate the effect of anxious attachment and suicidal ideation (Unstandardised interaction = 0.0238, SE = .0105, t = 2.2646, *p* = 0.0250). We found a moderate mediation effect of psychological pain on the relationship between CT, attachment anxiety, and suicidal ideation (index of moderated mediation = 0.0014, $CI_{95\%} = [0.0002;0.0032]$). This indicates that individuals with a developmental profile of CT and anxious attachment reported higher suicidal ideation the higher they reported psychological pain levels. The conditional indirect effect

<table><caption>**Table 1.** Description of socio-demographic and clinical characteristics of the whole sample (*n* = 161)</caption><thead><tr><th>Sociodemographic variables</th><th>n</th><th>%</th></tr></thead><tbody><tr><td>Age μ (SD)</td><td>37.63</td><td>(14.46)</td></tr><tr><td>Females</td><td>117</td><td>72.5</td></tr><tr><td>Civil status</td><td></td><td></td></tr><tr><td>Single</td><td>105</td><td>65.2</td></tr><tr><td>In relationship</td><td>56</td><td>34.8</td></tr><tr><td>Education</td><td></td><td></td></tr><tr><td>No high school diploma</td><td>43</td><td>26.7</td></tr><tr><td>High school diploma or more</td><td>118</td><td>73.3</td></tr><tr><td>Borderline personality disorder</td><td>38</td><td>23.5</td></tr><tr><td>Bipolar disorder</td><td>54</td><td>33.5</td></tr><tr><td>History of suicide attempts</td><td></td><td></td></tr><tr><td>Recently (&lt;8 days)</td><td>43</td><td>26.7</td></tr><tr><td>Previously (&gt;1 month)</td><td>52</td><td>32.3</td></tr><tr><td>Never</td><td>66</td><td>41.0</td></tr><tr><td>Self-rating questionnaires</td><td>μ (SD)</td><td></td></tr><tr><td>BDI total score minus suicidal item</td><td>18.17</td><td>(6.85)</td></tr><tr><td>BDI – suicidal ideation (item G)</td><td>1.06</td><td>(1.02)</td></tr><tr><td>NTS – total social pain score</td><td>53.86</td><td>(12.0)</td></tr><tr><td>PPP-VAS – worst psychological pain during the last 14 days</td><td>8.75</td><td>(1.75)</td></tr><tr><td>CTQ – total trauma score</td><td>49.61</td><td>(18.78)</td></tr><tr><td>CTQ – physical abuse</td><td>8.24</td><td>(4.74)</td></tr><tr><td>CTQ – emotional neglect</td><td>13.58</td><td>(5.21)</td></tr><tr><td>CTQ – physical neglect</td><td>8.19</td><td>(3.61)</td></tr><tr><td>CTQ – sexual abuse</td><td>7.07</td><td>(3.66)</td></tr><tr><td>CTQ – emotional abuse</td><td>12.54</td><td>(6.25)</td></tr><tr><td>RSQ – factor avoidance</td><td>21.48</td><td>(4.72)</td></tr><tr><td>RSQ – factor anxiety</td><td>15.39</td><td>(4.56)</td></tr><tr><td>RSQ – factor security</td><td>17.08</td><td>(3.88)</td></tr><tr><td>Clinician-rated questionnaire</td><td></td><td></td></tr><tr><td>IDS-C – total depression score</td><td>38.53</td><td>(8.70)</td></tr></tbody></table>

Abbreviations: BDI, Beck depression inventory; CTQ, childhood trauma questionnaire; IDS-C, clinician-rated Inventory for depressive symptomatology; PPP-VAS, physical psychological pain visual analogical scale; RSQ, relationship scale questionnaire.

was strongest in those reporting the highest psychological pain (64th percentile; effect = 0.0046, SE = 0.0020, 95% CI = [0.0013; 0.0090]) and did not reach significance in those reporting the lowest psychological pain (16th percentile, effect = 0.0019, SE = 0.0013, 95% CI = [-0.0003; 0.0048]). Psychological pain moderated the effect of attachment avoidance on suicidal ideation (Unstandardised interaction = -0.0232, SE = .0111, t = -2.0864, *p* = .0387). However, there was no indication of moderated mediation of psychological pain on the effect of CT over avoidance and security factor on suicidal ideation. Similar results were obtained for separated models of moderated mediation with emotional abuse and neglect, and physical abuse as predictors (shown in Figure 3, and Supplementary material).
<figure><img src="image_1.png" /><figcaption>**Figure 1.** Bivariate Spearman's Rho correlations, with only significant coefficients being displayed. Strength and direction of the relationship (positive or negative) of the correlation is labeled and additionally indicated by color (negative correlation depicted in red, positive correlation in blue) and size of the square. Correlation coefficients were interpreted according to Cohen's conventions [62]. A Rho coefficient $|ρ| ≥ 0.10$ indicates a weak relationship, $|ρ| ≥ 0.30$ a mediocre relationship, and $|ρ| ≥ 0.50$ a strong relationship.</figcaption></figure>

<figure><img src="image_2.png" /><figcaption>**Figure 2.** Mediation model on the effect of childhood trauma on suicidal ideation through its effect through three parallel attachment mediators. Regression coefficients are labeled with significant levels \*p < 0.05, \*\*p < 0.01, \*\*\*p < 0.001. Significant paths are in bold.</figcaption></figure>

Results remained stable even if borderline personality disorder was included as additional covariate (see Supplementary material).

**H2: No moderated mediation effect of attachment on relationship between CT and suicidal ideation, with social pain as moderator**
Last, we tested the hypothesized moderated mediation model, in which we introduced social pain as moderator. No effects were found when the total trauma score served as predictor, and the index of moderated mediation showed a tendency of significance = 0.0002, $CI_{95\%}$ = [0;0.0004]. Consecutively, we did not test for any trauma subtype. Results remained stable even if borderline

personality disorder was included as additional covariate (see Supplementary material).

## Discussion

Our results support hypotheses H1 and H2 suggesting a heightened vulnerability to suicidal ideation in anxious attachment which is worsened by psychological pain, but insensitive to social pain. Our results on the mediating effect of anxious attachment on the relationship between CT and suicidal ideation replicate results previously published by several research teams [8, 12, 63, 64] but
<figure><img src="image_3.png" /><figcaption>**Figure 1.** Bivariate Spearman's Rho correlations, with only significant coefficients being displayed. Strength and direction of the relationship (positive or negative) of the correlation is labeled and additionally indicated by color (negative correlation depicted in red, positive correlation in blue) and size of the square. Correlation coefficients were interpreted according to Cohen's conventions [62]. A Rho coefficient $|ρ| ≥ 0.10$ indicates a weak relationship, $|ρ| ≥ 0.30$ a mediocre relationship, and $|ρ| ≥ 0.50$ a strong relationship.</figcaption></figure>

<figure><img src="image_4.png" /><figcaption>**Figure 2.** Mediation model on the effect of childhood trauma on suicidal ideation through its effect through three parallel attachment mediators. Regression coefficients are labeled with significant levels \*p < 0.05, \*\*p < 0.01, \*\*\*p < 0.001. Significant paths are in bold.</figcaption></figure>

Results remained stable even if borderline personality disorder was included as additional covariate (see Supplementary material).

**H2: No moderated mediation effect of attachment on relationship between CT and suicidal ideation, with social pain as moderator**
Last, we tested the hypothesized moderated mediation model, in which we introduced social pain as moderator. No effects were found when the total trauma score served as predictor, and the index of moderated mediation showed a tendency of significance = 0.0002, $CI_{95\%}$ = [0;0.0004]. Consecutively, we did not test for any trauma subtype. Results remained stable even if borderline

personality disorder was included as additional covariate (see Supplementary material).

## Discussion

Our results support hypotheses H1 and H2 suggesting a heightened vulnerability to suicidal ideation in anxious attachment which is worsened by psychological pain, but insensitive to social pain. Our results on the mediating effect of anxious attachment on the relationship between CT and suicidal ideation replicate results previously published by several research teams [8, 12, 63, 64] but
<figure><img src="image_3.png" /></figure>

Covariates: IDS- C - Total depression score, history of last suicide attempt (recently, previously, never), sex

Likewise significant index of moderated mediation for models with predictors: emotional abuse & neglect, physical abuse

<caption>**Figure 3.** Mediation models on the conditional effect of childhood trauma on suicidal ideation through its effect through three parallel mediators, factors avoidance, anxiety, and security in function of the moderator psychological pain. Regression coefficients are labeled with significant levels \*p < 0.05, \*\*p < 0.01, \*\*\*p < 0.001. Regression coefficients for b are only displayed for the effect of RSQ-anxiety on suicidal ideation, as it was the only path where significant index of moderate mediation was found. The calculated b and c' coefficients are marked at the side of the diagram. Significant paths are in bold.</caption>

contradict findings from a previous study from our lab [48]. How-
ever, to the best of our knowledge this is the first study reporting a
moderated mediation effect of attachment and psychological pain on
the relationship between CT and suicidal ideation in a clinical setting.

A heightened vulnerability to suicidal ideation in anxious attach-
ment could reflect an imbalanced push-pull dynamic between asso-
ciative and reflective cognitive processes [65, 66]. In situations of
heightened stress, for example, induced through psychological pain
or triggered through circumstances that resemble the original con-
text, fast-associative processes guide perception [67, 68], attention,
and cognition [23, 69, 70]. In the case of anxious attachment, those
associative processes are based on care-related schemata that stem
from experiences of inconsistent, impulsive, frightening, or insensi-
tive care [41, 49] and entail a self-perception as helpless, incompetent
and dependent [49, 71]. Similar maladaptive personal schemata
(e.g. "I am deeply flawed" or "I am a failure") are suspected as core
feature of depressive symptomatology [72], and as the sequalae of
traumatic childhood experiences ("cognitive scars" [70]), especially
emotional trauma [73]. As our cohort presents depressive symptoms
and high levels of emotional trauma those maladaptive schemata are
likely to exist in our cohort and might be activated in subjects that
indicated a high level of psychological pain.

Further, reflective processes, especially *reflective functioning* –
the capacity to understand the behavior of oneself or another as
expression of underlying thoughts, beliefs, affective and motiv-
ational states [23] – are less accessible under extreme stress
[74]. In anxious attachment, this manifests in maladaptive coping
strategies that aim to evoke care from others but also amplify the
individual’s own distress [71] in a number of ways, including an
overestimation of threat, consistent pessimistic believes about their
own stress management capacities, low self-worth and overgener-
alization of past interpersonal injuries [25, 49, 71]. Heightened
suicidal ideation in anxious attachment could thus result from a)
the activation of dysfunctional schemata (“cognitive scars”) espe-
cially under psychological pain, and b) maladaptive stress-
increasing coping strategies. Together and over time, this could
aggravate already persisting negative thought spirals that finally
accumulate in suicidal ideation.

Thus, our analyses on anxious attachment might have also
reached significance due to a higher disclosure of suicidal
thoughts in general. A higher disclosure is in coherence with
the general orientation towards eliciting support from others that

is present in anxious attachment and was found to be associated
with clinical anxiety [75, 76]. In contrast, subjects that scored
higher on avoidant attachment might not have disclosed ideation
even though it was present. Non-disclosure of suicidal ideation is
common in depressive cohorts [75, 77] and might be linked in
our cohort to increased cognitive disengagement which is a
predominant strategy in avoidant attachment. Cognitive disen-
gagement might serve as a protective factor against suicidal
ideation in the short term but could increase the risk for suicidal
acts in the long term due to isolation and lack of close relation-
ships [43, 48, 79]. Our interpretation of higher disclosure and the
activation of maladaptive schemata also seems in line with the
fact that the present cohort presents higher values on suicidal
ideation and emotional trauma and therefore might be more
vulnerable to the here proposed mechanism compared to the
cohort of a former study [48]. Further, our cohort presents
average levels of secure attachment tendencies. Those did not
dampen the effect of CT on suicidal ideation – contrary to our
hypothesis - but it might also contribute to the disclosure of
suicidal ideation especially in contrast to avoidant attachment.

Last, we did not find a moderating effect of social pain on the
aforementioned mediation effect of attachment on CT and suicidal
ideation. It is conceivable that our experimental manipulation
(Cyberball paradigm) simply missed its mark, for example, because
the patients did not engage with it or that hospitalization buffered
the effect of the experimental manipulation. Also, social pain may
not be “intense” or of large personal valence necessary to activate
dysfunctional schemas and suicidal ideation.

Strengths and limitations of the present study

With 72.7% our cohort presents a high amount of females who are
supposedly under higher risk to display suicidal ideation [79]. Even
though we tested for heightened sensitivity by including sex as
covariate we cannot fully exclude the possibility that the effect
found here is not gender biased. Furthermore, the proposed explan-
ation of maladaptive cognitive schemata is well supported by the
literature, nevertheless, we did not assess schemata directly. In this
vein, recent papers have especially discussed the role of reflective
functioning as a trait vulnerability in insecurely attached individ-
uals [74] however no consensus has been found so far [12,
13]. Future studies might further investigate the role of associative
<figure><img src="image_5.png" /></figure>

Covariates: IDS- C - Total depression score, history of last suicide attempt (recently, previously, never), sex

Likewise significant index of moderated mediation for models with predictors: emotional abuse & neglect, physical abuse

<caption>**Figure 3.** Mediation models on the conditional effect of childhood trauma on suicidal ideation through its effect through three parallel mediators, factors avoidance, anxiety, and security in function of the moderator psychological pain. Regression coefficients are labeled with significant levels \*p < 0.05, \*\*p < 0.01, \*\*\*p < 0.001. Regression coefficients for b are only displayed for the effect of RSQ-anxiety on suicidal ideation, as it was the only path where significant index of moderate mediation was found. The calculated b and c' coefficients are marked at the side of the diagram. Significant paths are in bold.</caption>

contradict findings from a previous study from our lab [48]. How-
ever, to the best of our knowledge this is the first study reporting a
moderated mediation effect of attachment and psychological pain on
the relationship between CT and suicidal ideation in a clinical setting.

A heightened vulnerability to suicidal ideation in anxious attach-
ment could reflect an imbalanced push-pull dynamic between asso-
ciative and reflective cognitive processes [65, 66]. In situations of
heightened stress, for example, induced through psychological pain
or triggered through circumstances that resemble the original con-
text, fast-associative processes guide perception [67, 68], attention,
and cognition [23, 69, 70]. In the case of anxious attachment, those
associative processes are based on care-related schemata that stem
from experiences of inconsistent, impulsive, frightening, or insensi-
tive care [41, 49] and entail a self-perception as helpless, incompetent
and dependent [49, 71]. Similar maladaptive personal schemata
(e.g. "I am deeply flawed" or "I am a failure") are suspected as core
feature of depressive symptomatology [72], and as the sequalae of
traumatic childhood experiences ("cognitive scars" [70]), especially
emotional trauma [73]. As our cohort presents depressive symptoms
and high levels of emotional trauma those maladaptive schemata are
likely to exist in our cohort and might be activated in subjects that
indicated a high level of psychological pain.

Further, reflective processes, especially *reflective functioning* –
the capacity to understand the behavior of oneself or another as
expression of underlying thoughts, beliefs, affective and motiv-
ational states [23] – are less accessible under extreme stress
[74]. In anxious attachment, this manifests in maladaptive coping
strategies that aim to evoke care from others but also amplify the
individual’s own distress [71] in a number of ways, including an
overestimation of threat, consistent pessimistic believes about their
own stress management capacities, low self-worth and overgener-
alization of past interpersonal injuries [25, 49, 71]. Heightened
suicidal ideation in anxious attachment could thus result from a)
the activation of dysfunctional schemata (“cognitive scars”) espe-
cially under psychological pain, and b) maladaptive stress-
increasing coping strategies. Together and over time, this could
aggravate already persisting negative thought spirals that finally
accumulate in suicidal ideation.

Thus, our analyses on anxious attachment might have also
reached significance due to a higher disclosure of suicidal
thoughts in general. A higher disclosure is in coherence with
the general orientation towards eliciting support from others that

is present in anxious attachment and was found to be associated
with clinical anxiety [75, 76]. In contrast, subjects that scored
higher on avoidant attachment might not have disclosed ideation
even though it was present. Non-disclosure of suicidal ideation is
common in depressive cohorts [75, 77] and might be linked in
our cohort to increased cognitive disengagement which is a
predominant strategy in avoidant attachment. Cognitive disen-
gagement might serve as a protective factor against suicidal
ideation in the short term but could increase the risk for suicidal
acts in the long term due to isolation and lack of close relation-
ships [43, 48, 79]. Our interpretation of higher disclosure and the
activation of maladaptive schemata also seems in line with the
fact that the present cohort presents higher values on suicidal
ideation and emotional trauma and therefore might be more
vulnerable to the here proposed mechanism compared to the
cohort of a former study [48]. Further, our cohort presents
average levels of secure attachment tendencies. Those did not
dampen the effect of CT on suicidal ideation – contrary to our
hypothesis - but it might also contribute to the disclosure of
suicidal ideation especially in contrast to avoidant attachment.

Last, we did not find a moderating effect of social pain on the
aforementioned mediation effect of attachment on CT and suicidal
ideation. It is conceivable that our experimental manipulation
(Cyberball paradigm) simply missed its mark, for example, because
the patients did not engage with it or that hospitalization buffered
the effect of the experimental manipulation. Also, social pain may
not be “intense” or of large personal valence necessary to activate
dysfunctional schemas and suicidal ideation.

Strengths and limitations of the present study

With 72.7% our cohort presents a high amount of females who are
supposedly under higher risk to display suicidal ideation [79]. Even
though we tested for heightened sensitivity by including sex as
covariate we cannot fully exclude the possibility that the effect
found here is not gender biased. Furthermore, the proposed explan-
ation of maladaptive cognitive schemata is well supported by the
literature, nevertheless, we did not assess schemata directly. In this
vein, recent papers have especially discussed the role of reflective
functioning as a trait vulnerability in insecurely attached individ-
uals [74] however no consensus has been found so far [12,
13]. Future studies might further investigate the role of associative
schema and reflective processes in combination with other person-
ality traits in predicting suicidal ideation [13].

Further, we need to highlight that we analyze data in cross-
sectional way and conclude on a developmental process in retro-
spect. The gold standard for studying developmental processes is
typically long-term, prospective research. Prospective studies pro-
vide different figures on CT than retrospective ones [80]. However,
it is generally assumed that participants disclose traumatic experi-
ences more readily in retrospect [80]. Furthermore, a negative bias
in the recall of autobiographical memory in depression could bias
the admission of CT in our depressed cohort. However, a recent
meta-analysis reported that the overall effect size of negative recall
of explicit memory in depression is small and mostly bound to the
emotional valence of experiences [81]. The CTQ was especially
created to question about the frequency of abuse and neglect rather
than emotional valence to balance out a biased view. Additionally,
the CTQ shows good psychometric qualities, is widely used in
depressive cohorts, and we correct our statistical model for depres-
sion severity. We therefore believe that CT was realistically cap-
tured and that the association we report reflects a real association in
the cohort.

The described study is part of a bigger study during which physical
pain through thermal stimuli was also assessed. The latter was
assessed in a counterbalanced way before or after the Cyberball game,
which could have impacted social pain ratings. We did not control for
any such effect. Furthermore, we did not control for any medications.
It might be possible that medical treatment influenced the perception
of psychological pain. Last, we did not investigate intent of suicidal
ideation. Suicidal ideation is more common and luckily only a
fraction of those with ideation pass from idea to act [82].

Conclusion

This study suggests a developmental profile of suicidal ideation in
mood disorder that is characterized by the presence of CT and
insecure attachment, especially anxious attachment, that is sensi-
tive to experiences of psychological pain. Nevertheless, we cannot
conclude that avoidantly attached individuals do not present the
same mechanism, as they may not disclose those ideas. Future
research should therefore focus on a detailed assessment of attach-
ment, dysfunctional cognitive schemata, and reflective functioning.

**Supplementary material.** The supplementary material for this article can be
found at https://doi.org/10.1192/j.eurpsy.2023.2452.

**Data availability statement.** Information is available on request.

**Acknowledgements.** We would like to thank the patients who participated in the study and our dear colleagues, especially Kathlyne Dupuis-Maurin who collaborated in the data collection. We also thank Dr. Katherine Bryant for proofreading the manuscript.

**Author contribution.** E.O. obtained the funding. N.R. and E.O. collected the data. H.I., P.C., J.D., R.B., and E.O. designed the study. H.I. undertook the statistical analysis and wrote the first draft. All authors contributed to the writing and the correction of the manuscript.

**Financial support.** This work has received funding from AOI Montpellier Nimes (2013), as well as support from the French government under the Programme Investissements d'Avenir, Initiative d'Excellence d'Aix-Marseille Université via A*Midex (AMX-19-IET-004) and ANR (ANR-17-EURE-0029) funding. The funders had no further role in the study design, in the collection, analysis, and interpretation of data; nor in the writing or the decision to submit the article.

**Competing interest.** The authors declare none.

**Ethical standard.** Ethical approval was obtained (Sud Méditerranée IV - n° ID-RCB: 2013-A01029-36). An expense allowance of 60 euros was paid, and patients submitted their written consent.

References

[1] Turecki G. The molecular bases of the suicidal brain. Nat Rev Neurosci. 2014;15:802-16. doi:10.1038/nrn3839.

[2] Rabasco A, Andover MS. The interaction of dissociation, pain tolerance, and suicidal ideation in predicting suicide attempts. Psychiatry Res. 2020; 284:112661. doi:10.1016/j.psychres.2019.112661.

[3] Franklin JC, Ribeiro JD, Fox KR, Bentley KH, Kleiman EM, Huang X, et al. Risk factors for suicidal thoughts and behaviors: a meta-analysis of 50 years of research. Psychol Bull. 2017;143:187-232. doi:10.1037/bul0000084.

[4] Sokero TP, Melartin TK, Rytsala, HJ, Leskela US, Lestela-Mielonen PS, Isometsa ET. Suicidal ideation and attempts among psychiatric patients with major depressive disorder. J Clin Psychiatry. 2003;64:1094-100.

[5] Brown GK, Beck AT, Steer RA, Grisham JR. Risk factors for suicide in psychiatric outpatients: a 20-year prospective study. J Consult Clin Psychol. 2000;68:371-7. doi:10.1037/0022-006X.68.3.371.

[6] Van Heeringen K, Mann JJ. The neurobiology of suicide. Lancet Psychiatry. 2014;1:63-72. doi:10.1016/S2215-0366(14)70220-2.

[7] O'Connor RC, Kirtley OJ. The integrated motivational-volitional model of suicidal behaviour. Philos Trans R Soc B Biol Sci. 2018;373. doi:10.1098/rstb.2017.0268.

[8] Bahk YC, Jang SK, Choi KH, Lee SH. The relationship between childhood trauma and suicidal ideation: role of maltreatment and potential mediators. Psychiatry Investig. 2017;14:37-43. doi:10.4306/pi.2017.14.1.37.

[9] Angelakis I, Gillespie EL, Panagioti M. Childhood maltreatment and adult suicidality: a comprehensive systematic review with meta-analysis. Psychol Med. 2019;49:1057-78. doi:10.1017/S0033291718003823.

[10] Stagaki M, Nolte T, Feigenbaum J, King-Casas B, Lohrenz T, Fonagy P, et al. The mediating role of attachment and mentalising in the relationship between childhood maltreatment, self-harm and suicidality. Child Abus Negl. 2022;128:105576. doi:10.1016/j.chiabu.2022.105576.

[11] Danner Touati C, Miljkovitch R, Sirparanta A, Deborde AS. The role of attachment to the foster parent with regard to suicidal risk among adult survivors of childhood maltreatment. Child Abus Negl. 2022;128. doi: 10.1016/j.chiabu.2020.104886.

[12] Musetti A, Pingani L, Zagaria A, Uberti D, Meli S, Lenzo V, et al. Insecure adult attachment and reflective functioning as mechanisms of the relationship between traumatic life events and suicidal ideation: a path analysis. Front Psychol. 2022;13. doi:10.3389/fpsyg.2022.985148.

[13] Green J, Berry K, Danquah A, Pratt D. Attachment security and suicide ideation and behaviour: the mediating role of reflective functioning. Int J Environ Res Public Health. 2021;18:1-19. doi:10.3390/ijerph18063090.

[14] Cantón-Cortés D, Cortés MR, Cantón J. Child sexual abuse and suicidal ideation: the differential role of attachment and emotional security in the family system. Int J Environ Res Public Health. 2020;17. doi:10.3390/ijerph17093163.

[15] Bowlby J. Attachment and loss. Volume 1. New York: Basic Books; 1969.

[16] Ainsworth, M. D. Attachments across the life span. Bull N Y Acad Med. 1985;61(9):792.

[17] Bernstein DP, Stein JA, Newcomb MD, Walker E, Pogge D, Ahluvalia T, et al. Development and validation of a brief screening version of the childhood trauma questionnaire. Child Abus Negl. 2003;27:169-90. doi: 10.1016/S0145-2134(02)00541-0.

[18] Leeb RT, Paulozzi LJ, Melanson C, Simon TR, Arias I. Child maltreatment surveillance: uniform definitions for public health and recommended data elements, version 1.0. Annu Rev Clin Psychol. 2008;1:409-38.

[19] Mikulincer M, Shaver PR. The attachment behavioral system in adult-
hood: activation, psychodynamics, and interpersonal processes. Adv Exp
Soc Psychol. 2003;35:53–152. doi:10.1016/S0065-2601(03)01002-5.
schema and reflective processes in combination with other person-
ality traits in predicting suicidal ideation [13].

Further, we need to highlight that we analyze data in cross-
sectional way and conclude on a developmental process in retro-
spect. The gold standard for studying developmental processes is
typically long-term, prospective research. Prospective studies pro-
vide different figures on CT than retrospective ones [80]. However,
it is generally assumed that participants disclose traumatic experi-
ences more readily in retrospect [80]. Furthermore, a negative bias
in the recall of autobiographical memory in depression could bias
the admission of CT in our depressed cohort. However, a recent
meta-analysis reported that the overall effect size of negative recall
of explicit memory in depression is small and mostly bound to the
emotional valence of experiences [81]. The CTQ was especially
created to question about the frequency of abuse and neglect rather
than emotional valence to balance out a biased view. Additionally,
the CTQ shows good psychometric qualities, is widely used in
depressive cohorts, and we correct our statistical model for depres-
sion severity. We therefore believe that CT was realistically cap-
tured and that the association we report reflects a real association in
the cohort.

The described study is part of a bigger study during which physical
pain through thermal stimuli was also assessed. The latter was
assessed in a counterbalanced way before or after the Cyberball game,
which could have impacted social pain ratings. We did not control for
any such effect. Furthermore, we did not control for any medications.
It might be possible that medical treatment influenced the perception
of psychological pain. Last, we did not investigate intent of suicidal
ideation. Suicidal ideation is more common and luckily only a
fraction of those with ideation pass from idea to act [82].

Conclusion

This study suggests a developmental profile of suicidal ideation in
mood disorder that is characterized by the presence of CT and
insecure attachment, especially anxious attachment, that is sensi-
tive to experiences of psychological pain. Nevertheless, we cannot
conclude that avoidantly attached individuals do not present the
same mechanism, as they may not disclose those ideas. Future
research should therefore focus on a detailed assessment of attach-
ment, dysfunctional cognitive schemata, and reflective functioning.

**Supplementary material.** The supplementary material for this article can be
found at https://doi.org/10.1192/j.eurpsy.2023.2452.

**Data availability statement.** Information is available on request.

**Acknowledgements.** We would like to thank the patients who participated in the study and our dear colleagues, especially Kathlyne Dupuis-Maurin who collaborated in the data collection. We also thank Dr. Katherine Bryant for proofreading the manuscript.

**Author contribution.** E.O. obtained the funding. N.R. and E.O. collected the data. H.I., P.C., J.D., R.B., and E.O. designed the study. H.I. undertook the statistical analysis and wrote the first draft. All authors contributed to the writing and the correction of the manuscript.

**Financial support.** This work has received funding from AOI Montpellier Nimes (2013), as well as support from the French government under the Programme Investissements d'Avenir, Initiative d'Excellence d'Aix-Marseille Université via A*Midex (AMX-19-IET-004) and ANR (ANR-17-EURE-0029) funding. The funders had no further role in the study design, in the collection, analysis, and interpretation of data; nor in the writing or the decision to submit the article.

**Competing interest.** The authors declare none.

**Ethical standard.** Ethical approval was obtained (Sud Méditerranée IV - n° ID-RCB: 2013-A01029-36). An expense allowance of 60 euros was paid, and patients submitted their written consent.

References

[1] Turecki G. The molecular bases of the suicidal brain. Nat Rev Neurosci. 2014;15:802-16. doi:10.1038/nrn3839.

[2] Rabasco A, Andover MS. The interaction of dissociation, pain tolerance, and suicidal ideation in predicting suicide attempts. Psychiatry Res. 2020; 284:112661. doi:10.1016/j.psychres.2019.112661.

[3] Franklin JC, Ribeiro JD, Fox KR, Bentley KH, Kleiman EM, Huang X, et al. Risk factors for suicidal thoughts and behaviors: a meta-analysis of 50 years of research. Psychol Bull. 2017;143:187-232. doi:10.1037/bul0000084.

[4] Sokero TP, Melartin TK, Rytsala, HJ, Leskela US, Lestela-Mielonen PS, Isometsa ET. Suicidal ideation and attempts among psychiatric patients with major depressive disorder. J Clin Psychiatry. 2003;64:1094-100.

[5] Brown GK, Beck AT, Steer RA, Grisham JR. Risk factors for suicide in psychiatric outpatients: a 20-year prospective study. J Consult Clin Psychol. 2000;68:371-7. doi:10.1037/0022-006X.68.3.371.

[6] Van Heeringen K, Mann JJ. The neurobiology of suicide. Lancet Psychiatry. 2014;1:63-72. doi:10.1016/S2215-0366(14)70220-2.

[7] O'Connor RC, Kirtley OJ. The integrated motivational-volitional model of suicidal behaviour. Philos Trans R Soc B Biol Sci. 2018;373. doi:10.1098/rstb.2017.0268.

[8] Bahk YC, Jang SK, Choi KH, Lee SH. The relationship between childhood trauma and suicidal ideation: role of maltreatment and potential mediators. Psychiatry Investig. 2017;14:37-43. doi:10.4306/pi.2017.14.1.37.

[9] Angelakis I, Gillespie EL, Panagioti M. Childhood maltreatment and adult suicidality: a comprehensive systematic review with meta-analysis. Psychol Med. 2019;49:1057-78. doi:10.1017/S0033291718003823.

[10] Stagaki M, Nolte T, Feigenbaum J, King-Casas B, Lohrenz T, Fonagy P, et al. The mediating role of attachment and mentalising in the relationship between childhood maltreatment, self-harm and suicidality. Child Abus Negl. 2022;128:105576. doi:10.1016/j.chiabu.2022.105576.

[11] Danner Touati C, Miljkovitch R, Sirparanta A, Deborde AS. The role of attachment to the foster parent with regard to suicidal risk among adult survivors of childhood maltreatment. Child Abus Negl. 2022;128. doi: 10.1016/j.chiabu.2020.104886.

[12] Musetti A, Pingani L, Zagaria A, Uberti D, Meli S, Lenzo V, et al. Insecure adult attachment and reflective functioning as mechanisms of the relationship between traumatic life events and suicidal ideation: a path analysis. Front Psychol. 2022;13. doi:10.3389/fpsyg.2022.985148.

[13] Green J, Berry K, Danquah A, Pratt D. Attachment security and suicide ideation and behaviour: the mediating role of reflective functioning. Int J Environ Res Public Health. 2021;18:1-19. doi:10.3390/ijerph18063090.

[14] Cantón-Cortés D, Cortés MR, Cantón J. Child sexual abuse and suicidal ideation: the differential role of attachment and emotional security in the family system. Int J Environ Res Public Health. 2020;17. doi:10.3390/ijerph17093163.

[15] Bowlby J. Attachment and loss. Volume 1. New York: Basic Books; 1969.

[16] Ainsworth, M. D. Attachments across the life span. Bull N Y Acad Med. 1985;61(9):792.

[17] Bernstein DP, Stein JA, Newcomb MD, Walker E, Pogge D, Ahluvalia T, et al. Development and validation of a brief screening version of the childhood trauma questionnaire. Child Abus Negl. 2003;27:169-90. doi: 10.1016/S0145-2134(02)00541-0.

[18] Leeb RT, Paulozzi LJ, Melanson C, Simon TR, Arias I. Child maltreatment surveillance: uniform definitions for public health and recommended data elements, version 1.0. Annu Rev Clin Psychol. 2008;1:409-38.

[19] Mikulincer M, Shaver PR. The attachment behavioral system in adult-
hood: activation, psychodynamics, and interpersonal processes. Adv Exp
Soc Psychol. 2003;35:53–152. doi:10.1016/S0065-2601(03)01002-5.
[20] Main M, Kaplan N, Cassidy J. Security in infancy, childhood, and adult-hood: a move to the level of representation. Monogr Soc Res Child Dev. 2016;50:66–104.

[21] Bosmans G, Van Vlierberghe L, Bakermans-Kranenburg MJ, Kobak R, Hermans D, van IJzendoorn MH. A learning theory approach to attachment theory: exploring clinical applications. Clin Child Fam Psychol Rev. 2022;25:591–612. doi:10.1007/s10567-021-00377-x.

[22] Cyr C, Euser EM, Bakermans-Kranenburg MJ, Van Ijzendoorn MH. Attachment security and disorganization in maltreating and high-risk families: a series of meta-analyses. Dev Psychopathol. 2010;22:87–108. doi:10.1017/S0954579409990289.

[23] Luyten P, Campbell C, Allison E, Fonagy P. The mentalizing approach to psychopathology: state of the art and future directions. Annu Rev Clin Psychol. 2020;7:297–325. doi:10.1146/annurev-clinpsy-071919-015355.

[24] Fonagy P, Luyten P, Allison E. Epistemic petrification and the restoration of epistemic trust: a new conceptualization of borderline personality disorder and its psychosocial treatment. J Personal Disord. 2015;29:575–609. doi:10.1521/pedi.2015.29.5.575.

[25] Main M. Cross-cultural studies of attachment organization: recent studies, changing methodologies, and the concept of conditional strategies. Hum Dev. 1990;33:48–61. doi:10.1159/000276502.

[26] Mikulincer M, Shaver PR. “Can’t buy me love”: an attachment perspective on social support and money as psychological buffers. Psychol Inq. 2008; 19:167–73. doi:10.1080/10478400802631295.

[27] Zortea TC, Gray CM, O'Connor RC. The relationship between adult attachment and suicidal thoughts and behaviors: a systematic review. Arch Suicide Res. 2021;25:38–73. doi:10.1080/13811118.2019.1661893.

[28] Green J, Berry K, Danquah A, Pratt D. The role of psychological and social factors in the relationship between attachment and suicide: a systematic review. Clin Psychol Psychother. 2020;27:463–88. doi:10.1002/cpp.2445.

[29] O'Connor RC, Fraser L, Whyto M-C. A comparison of specific positive future expectancies and global hopelessness as predictors of suicidal ideation in a prosp. J Affect Disord. 2008;110:207–14. doi:10.1016/j.jad.2008.01.008.

[30] Klonsky DE, May AM. The three-step theory (3ST): a new theory of suicide rooted in the “ideation-to-action” framework. Int J Cogn Ther. 2015;8:114–29. doi:10.1521/ijct.2015.8.2.114.

[31] Shneidman ES. Perspectives on suicidology. Further reflections on suicide and psychache. Suicide Life Threat Behav. 1998;28:245–50.

[32] Shneidman ES. Commentary: suicide as psychache. J Nerv Ment Dis. 1993; 181:145–7. doi:10.1097/00005053-199303000-00001.

[33] Orbach I, Mikulincer M, Gilboa-Schechtman E, Sirota P. Mental pain and its relationship to suicidality and life meaning. Suicide Life-Threatening Behav. 2003;33:231–41. doi:10.1521/suli.33.3.231.23213.

[34] Maltsberger JT. The descent into suicide. Int J Psychoanal. 2004;85:653–68. doi:10.1516/3C96-URET-TLWX-6LWU.

[35] Orbach I, Mikulincer M, Sirota P, Gilboa-Schechtman E. Mental pain: a multidimensional operationalization and definition. Suicide Life-Threatening Behav. 2003;33:219–30. doi:10.1521/suli.33.3.219.23219.

[36] Ducasse D, Holden RR, Boyer L, Artéro S, Guillaume S, Courtet P, et al. It is illegal to post this copyrighted PDF on any website. J Clin Psychiatry. 2017; 78:16108. doi:10.4088/JCP.16r10732.

[37] Olié E, Guillaume S, Jaussent I, Courtet P, Jollant F. Higher psychological pain during a major depressive episode may be a factor of vulnerability to suicidal ideation and act. J Affect Disord. 2010;120:226–30. doi:10.1016/J.JAD.2009.03.013.

[38] Alacreu-Crespo A, Cazals A, Courtet P, Olié E. Brief assessment of psychological pain to predict suicidal events at one year in depressed patients. Psychother Psychosom. 2020;89:320–3. doi:10.1159/000506957.

[39] Eisenberger NI, Lieberman MD. Why rejection hurts: a common neural alarm system for physical and social pain. Trends Cogn Sci. 2004;8: 294–300. doi:10.1016/j.tics.2004.05.010.

[40] MacDonald G, Leary MR. Why does social exclusion hurt? The relationship between social and physical pain. Psychol Bull. 2005;131:202–23. doi: 10.1037/0033-2909.131.2.202.

[41] Abrutyn S. Toward a sociological theory of social pain. J Theory Soc Behav. 2023;1–21. doi:10.1111/jtsb.12371.

[42] Papini MR, Fuchs PN, Torres C. Behavioral neuroscience of psychological pain. Neurosci Biobehav Rev. 2015;48:53–69. doi:10.1016/j.neu-biorev.2014.11.012.

[43] Adam K. Suicidal behavior and attachment: a developmental model. In: Sperling M, Berman W, editors. Attachment in adults: clinical & developmental perspectives. New York: Guilford Press; 1994, p. 275–98.

[44] Williams K, Jarvis B. Cyberball: a program for use in research on interpersonal ostracism and acceptance. J Behav Res Methods. 2006;38:174–80. doi:10.3758/BF03192765.

[45] Zarrati I, Bermas H, Sabet M. The relationship between childhood trauma and suicide ideation: mediating role of mental pain. Ann Mil Heal Sci Res. 2019;1–7. doi:10.5812/amh.89266.

[46] Li X, You J, Ren Y, Zhou J, Sun R, Liu X, et al. A longitudinal study testing the role of psychache in the association between emotional abuse and suicidal ideation. J Clin Psychol. 2019;75:2284–92. doi:10.1002/jclp.22847.

[47] Martins LC, Campos RC, Morujão IS. The mediating role of tolerance for psychological pain in the relationship of childhood trauma to suicidal ideation in individuals with a substance use disorder. Br J Clin Psychol. 2022;61:197–213. doi:10.1111/bjc.12338.

[48] Ihme H, Olié E, Courtet P, El-Hage W, Zendjidjian X, Mazzola-Pomietto P, et al. Childhood trauma increases vulnerability to attempt suicide in adulthood through avoidant attachment. Compr Psychiatry. 2022;117. doi:10.1016/j.comppsych.2022.152333.

[49] Long M, Verbeke W, Ein-Dor T, Vrtička P. A functional neuro-anatomical model of human attachment (NAMA): insights from first- and second-person social neuroscience. Cortex. 2020;126:281–321. doi:10.1016/j.cortex.2020.01.010.

[50] Paquette D, Laporte L, Bigras M, Zoccolillo M. Validation de la version française du CTQ et prévalence de l'histoire de maltraitance. Sante Ment Que. 2004;29:201–20. doi:10.7202/008831ar.

[51] Griffin D, Bartholomew K. Relationship scales questionnaire. J Pers Soc Psychol. 1994.

[52] Guédeney N, Fermanian J, Bifulco A. Construct validation study of the relationship scales questionnaire (RSQ) on an adult sample. Encéphale. 2010;36:69–76. doi:10.1016/j.encep.2008.12.006.

[53] Beck AT, Steer RA, Brown G. Beck's depression inventory - II. APA Psych tests. San Antonio, TX: Psychological Corporation; 1996. doi:10.1037/t00742-000.

[54] Desseilles M, Perroud N, Guillaume S, Jaussent I, Genty C, Malafosse A, et al. Is it valid to measure suicidal ideation by depression rating scales? J Affect Disord. 2012;136:398–404. doi:10.1016/j.jad.2011.11.013.

[55] Zisook S, Trivedi MH, Warden D, Lebowitz B, Thase ME, Stewart JW, et al. Clinical correlates of the worsening or emergence of suicidal ideation during SSRI treatment of depression: an examination of citalopram in the STAR*D study. J Affect Disord. 2009;117:63–73. doi:10.1016/j.jad.2009.01.002.

[56] Nobile B, Olié E, Dubois J, Guillaume S, Gorwood P, Courtet P. Characteristics and treatment outcome of suicidal depression: two large naturalistic cohorts of depressed outpatients. Aust N Z J Psychiatry. 2022;56:347–64. doi:10.1177/00048674211025697.

[57] Joiner TE, Rudd MD, Rajab MH. Agreement between self- and clinician-rated suicidal symptoms in a clinical sample of young adults: explaining discrepancies. J Consult Clin Psychol. 1999;67:171–6. doi:10.1037/0022-006X.67.2.171.

[58] Rush JA, Giles DE, Schlesser MA, Fulton CL, Weissenburger J, Burns C. The inventory for depressive symptomatology (IDS): preliminary findings. Psychiatry Res. 1986;18:65–87. doi:10.1016/0165-1781(86)90060-0.

[59] Price DD, McGrath PA, Rafii A, Buckingham B. The validation of visual analogue scales as ratio scale measures for chronic and experimental pain. Pain. 1983;17:45–56. doi:10.1016/0304-3959(83)90126-4.

[60] Hayes AF. Introduction to mediation, moderation, and conditional process analysis: a regression-based approach. 2nd ed. New York: Guilford Press; 2017.

[61] Davidson R, MacKinnon JG. Estimation and inference in econometrics. New York: Oxford University Press; 1993.

[62] Cohen J. Statistical power analysis for the behavioral sciences. 2nd ed. Hillsday, NJ: Jacob Cohen; 1988.
[20] Main M, Kaplan N, Cassidy J. Security in infancy, childhood, and adult-hood: a move to the level of representation. Monogr Soc Res Child Dev. 2016;50:66–104.

[21] Bosmans G, Van Vlierberghe L, Bakermans-Kranenburg MJ, Kobak R, Hermans D, van IJzendoorn MH. A learning theory approach to attachment theory: exploring clinical applications. Clin Child Fam Psychol Rev. 2022;25:591–612. doi:10.1007/s10567-021-00377-x.

[22] Cyr C, Euser EM, Bakermans-Kranenburg MJ, Van Ijzendoorn MH. Attachment security and disorganization in maltreating and high-risk families: a series of meta-analyses. Dev Psychopathol. 2010;22:87–108. doi:10.1017/S0954579409990289.

[23] Luyten P, Campbell C, Allison E, Fonagy P. The mentalizing approach to psychopathology: state of the art and future directions. Annu Rev Clin Psychol. 2020;7:297–325. doi:10.1146/annurev-clinpsy-071919-015355.

[24] Fonagy P, Luyten P, Allison E. Epistemic petrification and the restoration of epistemic trust: a new conceptualization of borderline personality disorder and its psychosocial treatment. J Personal Disord. 2015;29:575–609. doi:10.1521/pedi.2015.29.5.575.

[25] Main M. Cross-cultural studies of attachment organization: recent studies, changing methodologies, and the concept of conditional strategies. Hum Dev. 1990;33:48–61. doi:10.1159/000276502.

[26] Mikulincer M, Shaver PR. "Can't buy me love": an attachment perspective on social support and money as psychological buffers. Psychol Inq. 2008; 19:167–73. doi:10.1080/10478400802631295.

[27] Zortea TC, Gray CM, O'Connor RC. The relationship between adult attachment and suicidal thoughts and behaviors: a systematic review. Arch Suicide Res. 2021;25:38–73. doi:10.1080/13811118.2019.1661893.

[28] Green J, Berry K, Danquah A, Pratt D. The role of psychological and social factors in the relationship between attachment and suicide: a systematic review. Clin Psychol Psychother. 2020;27:463–88. doi:10.1002/cpp.2445.

[29] O'Connor RC, Fraser L, Whyto M-C. A comparison of specific positive future expectancies and global hopelessness as predictors of suicidal ideation in a prosp. J Affect Disord. 2008;110:207–14. doi:10.1016/j.jad.2008.01.008.

[30] Klonsky DE, May AM. The three-step theory (3ST): a new theory of suicide rooted in the "ideation-to-action" framework. Int J Cogn Ther. 2015;8:114–29. doi:10.1521/ijct.2015.8.2.114.

[31] Shneidman ES. Perspectives on suicidology. Further reflections on suicide and psychache. Suicide Life Threat Behav. 1998;28:245–50.

[32] Shneidman ES. Commentary: suicide as psychache. J Nerv Ment Dis. 1993; 181:145–7. doi:10.1097/00005053-199303000-00001.

[33] Orbach I, Mikulincer M, Gilboa-Schechtman E, Sirota P. Mental pain and its relationship to suicidality and life meaning. Suicide Life-Threatening Behav. 2003;33:231–41. doi:10.1521/suli.33.3.231.23213.

[34] Maltsberger JT. The descent into suicide. Int J Psychoanal. 2004;85:653–68. doi:10.1516/3C96-URET-TLWX-6LWU.

[35] Orbach I, Mikulincer M, Sirota P, Gilboa-Schechtman E. Mental pain: a multidimensional operationalization and definition. Suicide Life-Threatening Behav. 2003;33:219–30. doi:10.1521/suli.33.3.219.23219.

[36] Ducasse D, Holden RR, Boyer L, Artéro S, Guillaume S, Courtet P, et al. It is illegal to post this copyrighted PDF on any website. J Clin Psychiatry. 2017; 78:16108. doi:10.4088/JCP.16r10732.

[37] Olié E, Guillaume S, Jaussent I, Courtet P, Jollant F. Higher psychological pain during a major depressive episode may be a factor of vulnerability to suicidal ideation and act. J Affect Disord. 2010;120:226–30. doi:10.1016/J.JAD.2009.03.013.

[38] Alacreu-Crespo A, Cazals A, Courtet P, Olié E. Brief assessment of psychological pain to predict suicidal events at one year in depressed patients. Psychother Psychosom. 2020;89:320–3. doi:10.1159/000506957.

[39] Eisenberger NI, Lieberman MD. Why rejection hurts: a common neural alarm system for physical and social pain. Trends Cogn Sci. 2004;8: 294–300. doi:10.1016/j.tics.2004.05.010.

[40] MacDonald G, Leary MR. Why does social exclusion hurt? The relationship between social and physical pain. Psychol Bull. 2005;131:202–23. doi: 10.1037/0033-2909.131.2.202.

[41] Abrutyn S. Toward a sociological theory of social pain. J Theory Soc Behav. 2023;1–21. doi:10.1111/jtsb.12371.

[42] Papini MR, Fuchs PN, Torres C. Behavioral neuroscience of psychological pain. Neurosci Biobehav Rev. 2015;48:53–69. doi:10.1016/j.neu-biorev.2014.11.012.

[43] Adam K. Suicidal behavior and attachment: a developmental model. In: Sperling M, Berman W, editors. Attachment in adults: clinical & developmental perspectives. New York: Guilford Press; 1994. p. 275–98.

[44] Williams K, Jarvis B. Cyberball: a program for use in research on interpersonal ostracism and acceptance. J Behav Res Methods. 2006;38:174–80. doi:10.3758/BF03192765.

[45] Zarrati I, Bermas H, Sabet M. The relationship between childhood trauma and suicide ideation: mediating role of mental pain. Ann Mil Heal Sci Res. 2019;1–7. doi:10.5812/amh.89266.

[46] Li X, You J, Ren Y, Zhou J, Sun R, Liu X, et al. A longitudinal study testing the role of psychache in the association between emotional abuse and suicidal ideation. J Clin Psychol. 2019;75:2284–92. doi:10.1002/jclp.22847.

[47] Martins LC, Campos RC, Morujão IS. The mediating role of tolerance for psychological pain in the relationship of childhood trauma to suicidal ideation in individuals with a substance use disorder. Br J Clin Psychol. 2022;61:197–213. doi:10.1111/bjc.12338.

[48] Ihme H, Olié E, Courtet P, El-Hage W, Zendjidjian X, Mazzola-Pomietto P, et al. Childhood trauma increases vulnerability to attempt suicide in adulthood through avoidant attachment. Compr Psychiatry. 2022;117. doi:10.1016/j.comppsych.2022.152333.

[49] Long M, Verbeke W, Ein-Dor T, Vrtička P. A functional neuro-anatomical model of human attachment (NAMA): insights from first- and second-person social neuroscience. Cortex. 2020;126:281–321. doi:10.1016/j.cortex.2020.01.010.

[50] Paquette D, Laporte L, Bigras M, Zoccolillo M. Validation de la version française du CTQ et prévalence de l'histoire de maltraitance. Sante Ment Que. 2004;29:201–20. doi:10.7202/008831ar.

[51] Griffin D, Bartholomew K. Relationship scales questionnaire. J Pers Soc Psychol. 1994.

[52] Guédeney N, Fermanian J, Bifulco A. Construct validation study of the relationship scales questionnaire (RSQ) on an adult sample. Encéphale. 2010;36:69–76. doi:10.1016/j.encep.2008.12.006.

[53] Beck AT, Steer RA, Brown G. Beck's depression inventory - II. APA Psych tests. San Antonio, TX: Psychological Corporation; 1996. doi:10.1037/t00742-000.

[54] Desseilles M, Perroud N, Guillaume S, Jaussent I, Genty C, Malafosse A, et al. Is it valid to measure suicidal ideation by depression rating scales? J Affect Disord. 2012;136:398–404. doi:10.1016/j.jad.2011.11.013.

[55] Zisook S, Trivedi MH, Warden D, Lebowitz B, Thase ME, Stewart JW, et al. Clinical correlates of the worsening or emergence of suicidal ideation during SSRI treatment of depression: an examination of citalopram in the STAR*D study. J Affect Disord. 2009;117:63–73. doi:10.1016/j.jad.2009.01.002.

[56] Nobile B, Olié E, Dubois J, Guillaume S, Gorwood P, Courtet P. Characteristics and treatment outcome of suicidal depression: two large naturalistic cohorts of depressed outpatients. Aust N Z J Psychiatry. 2022;56:347–64. doi:10.1177/00048674211025697.

[57] Joiner TE, Rudd MD, Rajab MH. Agreement between self- and clinician-rated suicidal symptoms in a clinical sample of young adults: explaining discrepancies. J Consult Clin Psychol. 1999;67:171–6. doi:10.1037/0022-006X.67.2.171.

[58] Rush JA, Giles DE, Schlesser MA, Fulton CL, Weissenburger J, Burns C. The inventory for depressive symptomatology (IDS): preliminary findings. Psychiatry Res. 1986;18:65–87. doi:10.1016/0165-1781(86)90060-0.

[59] Price DD, McGrath PA, Rafii A, Buckingham B. The validation of visual analogue scales as ratio scale measures for chronic and experimental pain. Pain. 1983;17:45–56. doi:10.1016/0304-3959(83)90126-4.

[60] Hayes AF. Introduction to mediation, moderation, and conditional process analysis: a regression-based approach. 2nd ed. New York: Guilford Press; 2017.

[61] Davidson R, MacKinnon JG. Estimation and inference in econometrics. New York: Oxford University Press; 1993.

[62] Cohen J. Statistical power analysis for the behavioral sciences. 2nd ed. Hillsday, NJ: Jacob Cohen; 1988.
[63] Lessard JC, Moretti MM. Suicidal ideation in an adolescent clinical sample: attachment patterns and clinical implications. J Adolesc. 1998;21:383-95. doi:10.1006/jado.1998.0169.

[64] Riggs SA, Jacobvitz D. Expectant parents' representations of early attachment relationships: associations with mental health and family history. J Consult Clin Psychol. 2002;70:195-204. doi:10.1037/0022-006X.70.1.195.

[65] Beevers CG. Cognitive vulnerability to depression: a dual process model. Clin Psychol Rev. 2005;25:975-1002. doi:10.1016/j.cpr.2005.03.003.

[66] Haeffel GJ, Abramson LY, Brazy PC, Shah JY, Teachman BA, Nosek BA. Explicit and implicit cognition: a preliminary test of a dual-process theory of cognitive vulnerability to depression. Behav Res Ther. 2007;45:1155-67. doi:10.1016/j.brat.2006.09.003.

[67] Collins NL, Feeney BC. Working models of attachment shape perceptions of social support: evidence from experimental and observational studies. J Pers Soc Psychol. 2004;87:363-83. doi:10.1037/0022-3514.87.3.363.

[68] Mogg K, Bradbury KE, Bradley BP. Interpretation of ambiguous information in clinical depression. Behav Res Ther. 2006;44:1411-9. doi:10.1016/j.brat.2005.10.008.

[69] Luyten P, Fonagy P. The stress-reward-mentalizing model of depression: an integrative developmental cascade approach to child and adolescent depressive disorder based on the research domain criteria (RDoC) approach. Clin Psychol Rev. 2018;64:87-98. doi:10.1016/j.cpr.2017.09.008.

[70] Wells TT, Vanderlind WM, Selby EA, Beevers CG. Childhood abuse and vulnerability to depression: cognitive scars in otherwise healthy young adults. Cogn Emot. 2014;28:821-33. doi:10.1080/02699931.2013.864258.

[71] Mikulincer M, Shaver PR. Attachment orientations and emotion regulation. Curr Opin Psychol. 2019;25:6-10. doi:10.1016/j.copsyc.2018.02.006.

[72] Beck AT. The evolution of the cognitive model of depression and its neurobiological correlates. Am J Psychiatry. 2008;165:969-77. doi:10.1176/appi.ajp.2008.08050721.

[73] Iffland B, Neuner F. Varying cognitive scars – differential associations between types of childhood maltreatment and facial emotion processing. Front Psychol. 2020;11:1-12. doi:10.3389/fpsyg.2020.00732.

[74] Bateman A, Fonagy P. 8-year follow-up of patients treated for borderline personality disorder: mentalization-based treatment versus treatment as usual. Am J Psychiatry. 2008;165:631-8. doi:10.1176/appi.ajp.2007.07.040636.

[75] Høyen KS, Solem S, Cohen LJ, Prestmo A, Hjemdal O, Vaaler AE, et al. Non-disclosure of suicidal ideation in psychiatric inpatients: rates and correlates. Death Stud. 2022;46:1823-31. doi:10.1080/07481187.2021.1879317.

[76] Husky MM, Zablith I, Alvarez Fernandez V, Kovess-Masfety V. Factors associated with suicidal ideation disclosure: results from a large population-based study. J Affect Disord. 2016;205:36-43. doi:10.1016/j.jad.2016.06.054.

[77] Cukrowicz KC, Duberstein PR, Vannoy SD, Lin EH, Unützer J. What factors determine disclosure of suicide ideation in adults 60 and older to a treatment provider? Suicide Life-Threat Behav. 2014;44:331-7. doi:10.1111/sltb.12075.

[78] Struck N, Krug A, Feldmann M, Yuksel D, Stein F, Schmitt S, et al. Attachment and social support mediate the association between childhood maltreatment and depressive symptoms. J Affect Disord. 2020;273:310-7. doi:10.1016/j.jad.2020.04.041.

[79] Canetto SS, Sakinofsky I. The gender paradox in suicide. Suicide Life Threat Behav. 1998;28:1-23.

[80] Baldwin JR, Reuben A, Newbury JB, Danese A. Agreement between prospective and retrospective measures of childhood maltreatment: a systematic review and meta-analysis. JAMA Psychiatry. 2019;76:584-93. doi:10.1001/jamapsychiatry.2019.0097.

[81] Everaert J, Vrijsen JN, Martin-Willett R, van de Kraats L, Joormann J. A meta-analytic review of the relationship between explicit memory bias and depression: depression features an explicit memory bias that persists beyond a depressive episode. Psychol Bull. 2022;148:435-63. doi:10.1037/bul0000367.

[82] Kessler RC, Berglund P, Nock M, Wang PS, Page P. Trends in suicide ideation, plans, gestures, and attempts in the United States, 1990-1992 to 2001-2003. JAMA. 2005;293:2487-95.
[63] Lessard JC, Moretti MM. Suicidal ideation in an adolescent clinical sample: attachment patterns and clinical implications. J Adolesc. 1998;21:383-95. doi:10.1006/jado.1998.0169.

[64] Riggs SA, Jacobvitz D. Expectant parents' representations of early attachment relationships: associations with mental health and family history. J Consult Clin Psychol. 2002;70:195-204. doi:10.1037/0022-006X.70.1.195.

[65] Beevers CG. Cognitive vulnerability to depression: a dual process model. Clin Psychol Rev. 2005;25:975-1002. doi:10.1016/j.cpr.2005.03.003.

[66] Haeffel GJ, Abramson LY, Brazy PC, Shah JY, Teachman BA, Nosek BA. Explicit and implicit cognition: a preliminary test of a dual-process theory of cognitive vulnerability to depression. Behav Res Ther. 2007;45:1155-67. doi:10.1016/j.brat.2006.09.003.

[67] Collins NL, Feeney BC. Working models of attachment shape perceptions of social support: evidence from experimental and observational studies. J Pers Soc Psychol. 2004;87:363-83. doi:10.1037/0022-3514.87.3.363.

[68] Mogg K, Bradbury KE, Bradley BP. Interpretation of ambiguous information in clinical depression. Behav Res Ther. 2006;44:1411-9. doi:10.1016/j.brat.2005.10.008.

[69] Luyten P, Fonagy P. The stress-reward-mentalizing model of depression: an integrative developmental cascade approach to child and adolescent depressive disorder based on the research domain criteria (RDoC) approach. Clin Psychol Rev. 2018;64:87-98. doi:10.1016/j.cpr.2017.09.008.

[70] Wells TT, Vanderlind WM, Selby EA, Beevers CG. Childhood abuse and vulnerability to depression: cognitive scars in otherwise healthy young adults. Cogn Emot. 2014;28:821-33. doi:10.1080/02699931.2013.864258.

[71] Mikulincer M, Shaver PR. Attachment orientations and emotion regulation. Curr Opin Psychol. 2019;25:6-10. doi:10.1016/j.copsyc.2018.02.006.

[72] Beck AT. The evolution of the cognitive model of depression and its neurobiological correlates. Am J Psychiatry. 2008;165:969-77. doi:10.1176/appi.ajp.2008.08050721.

[73] Iffland B, Neuner F. Varying cognitive scars – differential associations between types of childhood maltreatment and facial emotion processing. Front Psychol. 2020;11:1-12. doi:10.3389/fpsyg.2020.00732.

[74] Bateman A, Fonagy P. 8-year follow-up of patients treated for borderline personality disorder: mentalization-based treatment versus treatment as usual. Am J Psychiatry. 2008;165:631-8. doi:10.1176/appi.ajp.2007.07.040636.

[75] Høyen KS, Solem S, Cohen LJ, Prestmo A, Hjemdal O, Vaaler AE, et al. Non-disclosure of suicidal ideation in psychiatric inpatients: rates and correlates. Death Stud. 2022;46:1823-31. doi:10.1080/07481187.2021.1879317.

[76] Husky MM, Zablith I, Alvarez Fernandez V, Kovess-Masfety V. Factors associated with suicidal ideation disclosure: results from a large population-based study. J Affect Disord. 2016;205:36-43. doi:10.1016/j.jad.2016.06.054.

[77] Cukrowicz KC, Duberstein PR, Vannoy SD, Lin EH, Unützer J. What factors determine disclosure of suicide ideation in adults 60 and older to a treatment provider? Suicide Life-Threat Behav. 2014;44:331-7. doi:10.1111/sltb.12075.

[78] Struck N, Krug A, Feldmann M, Yuksel D, Stein F, Schmitt S, et al. Attachment and social support mediate the association between childhood maltreatment and depressive symptoms. J Affect Disord. 2020;273:310-7. doi:10.1016/j.jad.2020.04.041.

[79] Canetto SS, Sakinofsky I. The gender paradox in suicide. Suicide Life Threat Behav. 1998;28:1-23.

[80] Baldwin JR, Reuben A, Newbury JB, Danese A. Agreement between prospective and retrospective measures of childhood maltreatment: a systematic review and meta-analysis. JAMA Psychiatry. 2019;76:584-93. doi:10.1001/jamapsychiatry.2019.0097.

[81] Everaert J, Vrijsen JN, Martin-Willett R, van de Kraats L, Joormann J. A meta-analytic review of the relationship between explicit memory bias and depression: depression features an explicit memory bias that persists beyond a depressive episode. Psychol Bull. 2022;148:435-63. doi:10.1037/bul0000367.

[82] Kessler RC, Berglund P, Nock M, Wang PS, Page P. Trends in suicide ideation, plans, gestures, and attempts in the United States, 1990-1992 to 2001-2003. JAMA.2005;293:2487-95.