How suicidal individuals think about the future – A systematic review
Creators: name: Bjerkestrand, Lukas
name: Bø, Simen
name: Norman, Elisabeth
Publisher: name: Open Science Framework
Year: 2022
Subjects: subject: Social and Behavioral Sciences
subject: Psychology
subject: FOS: Psychology

description: Authors Lukas H. Bjerkestrand*1, Elisabeth Norman1, 2 and Simen Bø2 Contact information 1 Department of Psychological Science, Faculty of Psychology, University of Bergen, Norway. 2 Department of Strategy and Management, Norwegian School of Economics, Bergen, Norway. E-mail: Lukas H. Bjerkestrand lbj038@uib.no * corresponding author Contributions LHB, EN and SB contributed to the study design and approved the protocol of the review. LHB will conduct the literature search, screening, and coding of study information. LHB, EN and SB will contribute to writing the first draft and approve the final draft of the manuscript. Introduction Suicide is the fourth most common cause of death among young adults and adolescents in the world, preceded only by road injury, tuberculosis, and interpersonal violence (WHO, 2021). Experiencing suicide can create a distinct kind of grief compared to regular loss, involving feelings of guilt and responsibility, as well as confusion from the lack of perceived meaning behind the death (Shields et al., 2014). Suicide also sparks intense long-lasting emotions such as intense pain, distress, and even fear (Shields et al., 2014). Furthermore, experiencing another’s suicide increases the vulnerability for mental disorders and engagement in both suicidal thoughts and behaviors (Pitman et al., 2014). As approximately 700 000 people die from suicide attempts each year (WHO, 2021), understanding the development of suicide is of utmost importance for both society and those affected by suicide. Being suicidal leaves the individual with an irregular or distorted view of their relations to others, and of the self. Suicidal individuals experience less belongingness and connectedness to others (Van Orden et al, 2011), and they perceive themselves as being a burden on others to such an extent that they believe friends and family would be better off if they ceased to exist (Van Orden et al, 2011). Suicidal individuals hold a strong negative view of themselves, characterized by isolation, degradation, and shame (Cohen et al, 2018)., Mason et al (2022) found that male participants reportedly experience self-disgust, feelings of being worthless, and an aggregation of negative emotions leading up to a suicide attempt. These male participants reported a “fear of their disgustingness being exposed” (Mason et al, 2022, p. 8), which was a key factor in suicide development. Being suicidal is a distinctively different experience to not being suicidal. Moreover, research on suicide shows that suicidal individuals have further distinctive and dysfunctional ways of thinking about the future (Rosario-Williams et al., 2021; Pollak et al.; 2020, O’Connor 2012), which influences their suicidal thoughts and behaviors (O’Connor et al, 2018). The altered future-oriented cognition of the suicidal individual might explain why suicide is perceived as a valid option and understanding their cognition might aid in developing clinical techniques to prevent future suicide. Recently, efforts to understand the development of suicidal behavior has resulted in the integrated motivational-volitional model by O’Connor and Kirtley (2018), which consist of three phases: the pre-motivational phase, the motivational phase, and the volitional phase. The first phase consists of the background factors of individuals which influence later development of suicidal thinking. These background factors are complicated interactions between environmental, cognitive, biological, and social factors, such as childhood experiences, amount and quality of relationships, genetics etc. In other words, this phase argues that some are more predisposed for development of suicidal thoughts and behaviors than others. The second phase consists of the development of suicidal thinking and the factors that influence this development. First, suicidal thoughts are assumed to be rooted in experiencing defeat and feelings of humiliation, that in combination with poor self-regulation skills, such as coping strategies, rumination, and problem-solving skills, lead to entrapment. Entrapment is the term for experiencing a defeat as inescapable, and deterministically accepting there is nothing that can change the situation. An example of an inescapable situation can be being bullied without being able to transfer to another school. In the latter stages of the second phase, individuals who are able to think positive about the future, have functional and realistic goal setting-behavior, and are able to pursue goals usually do not develop suicidal thoughts. If individuals instead perceive themselves as a burden to others, experience less belongingness and social support, and have fewer positive thoughts about the future, this contributes to the formation of suicidal thought. If the individual fails to arrest the development of suicidal thoughts, they are in the volitional phase according to the IMV-model. This phase consists of factors that influences individuals with suicidal thoughts to engage in suicidal behavior. Individuals are more predisposed to engage in suicidal behavior if they previously attempted suicide, have knowledge of and access to forms of suicide – such as stacking pills –, have certain personality traits – such as impulsivity –, or are experiencing intrusive images of their future suicide, having reduced sensitivity to pain, or reduced fear of death. As future thinking and goal pursuit are seen as important determinants of the formation of suicidal ideation and the transition to suicidal behavior, understanding the structure of future-oriented cognition is imperative to understanding suicidal individuals. One type of future-oriented cognition is episodic prospection, which concerns thoughts about specific autobiographical events in the future (Szpunar et al., 2014). There are four recognized subcategories of episodic future thinking: simulation, prediction, intention, and planning. Episodic simulation is defined as “the construction of a detailed mental representation of a specific autobiographical future event” (Szpunar et al, 2014, p. 18416). In other words, a fantasy or an image of a specific, personally relevant, future situation. Next, episodic prediction is “the estimation of the likelihood of and/or one’s reaction to a specific autobiographical future event” (Szpunar et al, 2014, p. 18417), meaning the personally evaluated probability of an imagined event occurring in the future and the emotions that could arise if the imagined event comes to pass. Third, episodic intention is “the mental act of setting a goal in relation to a specific autobiographical event” (Szpunar et al, 2014, p. 18418). This category includes the formation of all personally relevant goals, whether they are long-lasting or day-to-day goals. Lastly, episodic planning is “the identification and organization of steps needed to arrive at a specific autobiographical event or outcome” (Szpunar et al, 2014, p. 18418). In other words, thinking about and planning what needs to be done to achieve a goal. To contrast, semantic prospection also concerns the future, but involves generic or abstract states of the world. There are contradictions in the literature that warrant attention. Firstly, studies on episodic simulation are incongruent. According to some studies, suicidal individuals report an inability to simulate positive future events unlike non-suicidal people (Rosario-Williams et al, 2021), yet others report that suicidal individuals have more positive future fantasies than non-suicidal individuals (Pollak et al, 2021; O’Connor et al, 2015). Other studies show that suicidal individuals experience vivid, intrusive images of their ‘future suicide’ called “flash-forwards”, that are perceived as disturbing to the individual (Schultebraucks et al, 2020; McEvoy et al, 2017; Ng et al, 2016). However, Crane et al. (2011) found that 15 percent of participants found these images comforting. Lastly, individuals with suicidal ideation, recent self-harm or recent suicide attempts have altered goal-related behavior. When failing to achieve a desired goal, individuals struggle to disengage from this unattainable goal because they contribute their future well-being to that goal (Coughlan et al., 2017; O’Connor et al, 2012). According to O’Connor et al (2012) suicidal individuals struggle to come up with or reengage in new goals, which leaves them in a dysfunctional goal setting loop with constant feelings of failure (O’Connor et al., 2012). However, Coughlan et al. (2017) found that suicidal individuals have an equal ability to think of future goals as healthy controls, but they evaluate the likelihood of goal completion as lower than healthy controls (Coughlan et al., 2017). Regardless, both studies show that suicidal individuals experience dysfunctional goal-setting and goal-pursuing behavior. This paper will review characteristics in the content of episodic prospection in individuals with suicidal thoughts and behaviors, compared to other populations. Specifically, we will examine studies exploring the content and characteristics of all forms of episodic prospection, including episodic simulation, episodic prediction, episodic intention, and episodic planning in individuals that are experiencing or have experienced suicidal ideation, non-suicidal self-harm and previous suicide attempts compared to other populations. A secondary goal of this review is to examine the effects of future-thinking interventions for individuals with suicidal thoughts and behaviors. Methods Eligibility criteria Studies will be selected according to the criteria outlined below. We will include all studies with study designs which includes participants with either suicidal ideation, non-suicidal self-harm, or previous suicide attempts, and one or more control groups or reference groups without any form of suicidal ideation, non-suicidal self-harm, or previous suicide attempts. Additionally, the studies must include measurements of episodic prospection, defined as thoughts related to specific autobiographical events that may occur in the future. Importantly, this is not necessarily limited to episodic simulation, episodic prediction, episodic intention, or episodic planning. Episodic prospections not fitting into any of these categories, will be categorized as “other episodic prospections”. Furthermore, studies must include measurements of suicidal ideation, non-suicidal self-injury or previous suicide attempts. Study designs can be cross-sectional, longitudinal, or experimental, with the important criterion that the study assesses both individuals with suicidal thoughts and behaviors, and individuals without. Participants with either adults or adolescents will be included. We will utilize 2 frameworks in this study. Firstly, we will use the Integrated Motivational-Volitional model (O’Connor &amp; Kirtley, 2018) to define which phase of suicidal thinking the participants are in (i.e., suicidal ideation or past suicide attempt). Secondly, we will use Szpunar's taxonomy for future-oriented cognition (Szpunar, et al., 2014). Information sources The search will be conducted in the databases PsycINFO and Web Of Science. Searches in PsycINFO will be conducted within the OVID interface. Search strategy We will search the included databases without any time restrictions. The search will contain the following search terms: (“prospection*” OR “prospective cognition*” OR “future-oriented cognition*” OR “future-oriented think*” OR future-oriented thought*” OR “future-directed cognition*” OR “future-directed think*” OR “future-directed thought*” OR “future episodic thought*” OR “future episodic think*” OR "future think*” OR “future thought*” OR “autonoetic consciousness” OR fatalism OR “episodic simulation*” OR (“future N2 simulation”) OR “episodic construction*” OR “future imag*” OR “future personal representation*” OR “future envis*” OR “future projection*” OR “self-projection*” OR daydream OR “flash-forward*” OR “flash forward*” OR “mental time-travel” OR “mental time travel” OR “episodic prediction*” OR “affective forecasting*” OR “affective misforecasting*” OR “thought-action fusion” OR “episodic intention*” OR “goal setting” OR “goal-related thought*” OR “desired goal*” OR “painful engagement” OR “implementation intention*” OR “intention formation” OR “conditional goal*” OR “episodic plan*” OR “autobiographical plan*” OR “planning abilit*” OR “goal attainment” OR “goal disengagement” OR “goal reengagement”) AND (suicid* OR parasuicid* OR “self-harm*” OR “self harm*” OR “self-injurious behavior” OR “self-injurious behaviour” OR “self-mutilation” OR “self-inflicted wounds” OR “non-suicidal self-injury”) Draft of full search for one database (PsycINFO) This is the full search for PsycINFO. The search in Web of Science will be conducted in the same manner. The items above will be searched in multiple fields, covering title, abstract, original title, subject heading word, unique identifiers, table of content, key concepts, tests &amp; measures, mesh, name of substance word, floating sub-heading word, keyword heading word, organism supplementary concept word, protocol supplementary concept word, rare disease supplementary concept word and synonyms. 1: (“prospection*” OR “prospective cognition*” OR “future-oriented cognition*” OR “future-oriented think*” OR future-oriented thought*” OR “future-directed cognition*” OR “future-directed think*” OR “future-directed thought*” OR “future episodic thought*” OR “future episodic think*” OR "future think*” OR “future thought*” OR “autonoetic consciousness” OR fatalism OR “episodic simulation*” OR (“future N2 simulation”) OR “episodic construction*” OR “future imag*” OR “future personal representation*” OR “future envis*” OR “future projection*” OR “self-projection*” OR daydream OR “flash-forward*” OR “flash forward*” OR “mental time-travel” OR “mental time travel” OR “episodic prediction*” OR “affective forecasting*” OR “affective misforecasting*” OR “thought-action fusion” OR “episodic intention*” OR “goal setting” OR “goal-related thought*” OR “desired goal*” OR “painful engagement” OR “implementation intention*” OR “intention formation” OR “conditional goal*” OR “episodic plan*” OR “autobiographical plan*” OR “planning abilit*” OR “goal attainment” OR “goal disengagement” OR “goal reengagement”) 2: (suicid* OR parasuicid* OR “self-harm*” OR “self harm*” OR “self-injurious behavior” OR “self-injurious behaviour” OR “Self-mutilation” OR “Self-inflicted wounds” OR “non-suicidal self-injury”) 3: 1 and 2 4: limit to 3 (Norwegian or English) Data management Endnote will be used to store selected papers, manage references and remove duplicates. Duplicates will be removed by title, year, and juxtaposing author names. Microsoft Excel will be used to screen for both title and abstract and in full-text review. In addition, Microsoft Excel will be used to organize the papers’ content by type of prospection and suicidal engagement as well as reasons for inclusion. Selection process One author (LHB) will screen all titles and abstracts identified from the search items based on the inclusion criteria. All potentially relevant articles will be included, and one author (LHB) will conduct the full-text reviews from the selected articles. During selection process, the author (LHB) will explain why possible excluded studies were excluded. Uncertain cases will be discussed with a senior author (SB). Unresolved disagreements will be determined by the second senior author (EN). The search will be conducted as a pilot-test before the selection process will find place. EndNote will be used for data storage, and aid in removal of duplicates during the selection process. If there are uncompleted articles, the articles will be excluded. Data collection process One author (LHB) will collect the data from all included studies after full-text screening, and record reasonings for what data to extract. Data extracted will include demographic information, methodology, intervention details, and all reported outcomes. If we encounter any uncertainties or missing data pertaining to the main research questions in the selected studies, one author (LHB) will contact the corresponding author of the studies for clarification or access to the data set. A maximum of two e-mail attempts will be made to reach the corresponding author. The data includes all specified in the “data items”-section below. Data items We will extract information about author, title, abstract, year of publication, type of research design, type of experimental design, number of conditions, population, and sample size. In addition, we will extract information regarding methodological aspects of the future-oriented cognition (i.e., future thinking task) and suicidality (e.g., Becks suicidal ideation scale), and if noted, the negative or positive valence associated with the type of prospection. Moreover, we will categorize future-oriented cognition after Szpunar's 4 constructs of episodic prospection: episodic simulation, episodic prediction, episodic intention, and episodic planning. For example, studies measuring future forecasting might be categorized as episodic prediction. We will also include episodic prospection which does not categorize into one of these four categories, using a fifth category for “other episodic prospection”. For outcome measures, we will extract whether the participants were engaging in suicidal ideation, suicidal behaviors, or non-suicidal self-injurious behavior at the time of study or recalling such suicidal behavior from memory. Furthermore, we will extract information about methodological manipulations, such as length of study, number of intervention points and interventions, as well as the experimental instructions the participants received and length of intervention for participants. If sufficient information concerning the data items is not reported in the article, we will attempt to get access to the original data. If the data is available as a supplement to the article, we will utilize the article. However, if the data is not available, a maximum of two attempts to reach the author by e-mail will be made to gain access to the article and its original data file. If the data is still not retrieved or containing insufficient information after these steps, the article will be excluded from the synthesis. Outcomes and prioritization The primary outcome of this study is the content and characteristics of episodic prospection (encompassing particularly episodic simulation, episodic prediction, episodic intention, and episodic planning), measured with any instrument, in participants with suicidal ideation, non-suicidal self-harm or previous suicide attempts, defined in accordance with the eligibility criteria. Secondary outcomes include: - Entrapment - Attitudes towards suicide - Attitudes towards dying - Fearlessness about death - Impulsivity - Thought-action fusion - Fatalism - Hopelessness - Pessimism Risk of bias in individual studies There will be no formal assessment of the Risk of bias of individual studies in this narrative synthesis, as agreed upon by the coauthors. Data synthesis The review will use narrative synthesis. As this study does not assess risk of bias, all studies matching the eligibility criteria will be included. Tables will be used to give descriptive statistics of all included summaries. The results will be showed in accordance with type of future-oriented cognition identified in the literature. The findings will be shown in the following manner: 1) study characteristics and sample characteristics; 2) interventions or measurements of future-oriented cognition; 3) measurement of suicidal thoughts and behaviors; 4) results for future-oriented cognition in individuals with suicidal thoughts or behaviors; 5) other outcome measures in addition to future-oriented cognitions. The final section will be a summary of the strength of evidence and to what degree the different future-oriented cognition constructs diverge or converge. 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