Korean Clinical Psychology Association

Korean Journal of Clinical Psychology - Vol. 40 , No. 3

[ Original Article ]
Korean Journal of Clinical Psychology - Vol. 40, No. 3, pp.177-191
Abbreviation: KJCP
ISSN: 1229-0335 (Print) 2733-4538 (Online)
Print publication date 30 Aug 2021
Received 26 Jan 2021 Revised 12 May 2021 Accepted 13 May 2021
DOI: https://doi.org/10.15842/kjcp.2021.40.3.001

의사결정나무분석을 이용한 자살 시도 계획 수준 및 충동성에 대한 심리사회적 예측 요인
김효중 ; 유성은
충북대학교 심리학과

Psychosocial Factors Predicting Planning Level and Impulsivity of Suicide Attempt using a Decision Tree Analysis
Hyojoong Kim ; Sungeun You
Department of Psychology, Chungbuk National University, Cheongju, Korea
Correspondence to : Sungeun You, Department of Psychology, Chungbuk National University, 1 Chungdae-ro, Seowon-gu, Cheongju, Korea; E-mail: syou@chungbuk.ac.kr
This work is based on the Master’s thesis of the first author (H.K.).


© 2021 Korean Clinical Psychology Association
Funding Information ▼

초록

자살 시도는 장기적인 계획에 의해 실행될 수도 있고 급성 위기 상황에서 충동적으로 실행될 수도 있다. 효과적인 자살 예방과 개입을 위해서는 이러한 자살 시도의 행동 특성을 예측하는 차별적인 요인을 밝히는 것이 중요하다. 본 연구에서는 자살 시도 이전 계획 수준과 자살 시도 당일 충동성을 예측하는 심리사회적 요인을 각각 알아보았다. 특히, 의사결정나무분석을 이용하여 자살 시도의 계획 수준 및 충동성을 예측하는 요인들 간의 상호작용 효과를 알아보는 것을 주요 목적으로 하였다. 이를 위해 성별과 연령대를 층화 표집하여 자살 시도 경험이 있는 성인 300명을 모집하였다. 온라인 설문조사를 통해 자살 행동 이전 계획 수준 및 자살 시도 당일 충동성을 측정하였고, 주요 예측 변인으로 우울, 절망감, 부정 긴급성, 인지적 유연성, 스트레스 경험을 측정하였다. 의사결정나무분석 결과, 자살 시도 이전의 계획 수준은 우울과 부정 긴급성의 상호작용이 예측하였다. 구체적으로 우울 수준이 높을수록 자살 시도 계획 수준이 높았고, 우울 수준이 낮은 경우에는 부정 긴급성이 높을수록 자살 시도 계획 수준이 높게 나타났다. 자살 시도 당일 충동성은 우울, 인지적 유연성(통제, 대안)과 절망감의 상호작용이 예측하였다. 첫째, 우울 수준이 낮을수록 자살 시도 당일 충동성이 높았다. 둘째, 우울 수준이 낮은 경우 통제와 대안 수준이 높을수록 자살 시도 당일 충동성이 높았고, 셋째, 우울, 통제, 대안 수준이 모두 낮을 경우에는 절망감이 높을수록 자살 시도 당일 충동성이 높게 나타났다. 본 연구 결과는 자살 시도 이전 계획 수준이 높은 자살 시도자와 급성 위기 상황에서 충동적으로 자살 시도를 하는 사람들을 위한 차별화된 개입 전략이 필요함을 시사한다.

Abstract

Suicide attempt is usually made as a result of distal planning and/or proximal impulsivity during an acute crisis. The aim of this study was to examine the interaction effects of psychosocial factors that predict the planning level and impulsivity of suicide attempt. Using stratified sampling by age and sex, 300 adults with a history of suicide attempt were recruited. Planning level and impulsivity of the most recent suicide attempt were assessed, and the following were assessed and used as the main predictors: depression, hopelessness, negative urgency, cognitive flexibility, and stress experience. Using decision tree analysis, the results indicated that the interaction between depression and negative urgency predicted the planning level of suicide attempt. Specifically, the higher the level of depression, the higher the planning level of a suicide attempt. In cases of low levels of depression, a higher level of negative urgency predicted the planning level. The psychosocial factors that predicted impulsivity of suicide attempt were the interaction of depression, cognitive flexibility (control and alternatives), and hopelessness. First, the lower the level of depression, the greater the impulsivity of a suicide attempt. Second, when depression levels were low, higher levels of control and alternatives predicted the impulsivity. Third, when the levels of depression, control, and alternatives were low, hopelessness predicted the impulsivity. The results of this study suggest that differential intervention strategies are needed for individuals planning suicide and those who may act impulsively during an acute crisis.


Keywords: suicide attempt, suicide planning, impulsive suicide attempt, decision tree analysis
키워드: 자살 시도, 자살 계획, 충동적 자살 시도, 의사결정나무분석

Acknowledgments

This work was supported by the Ministry of Education of the Republic of Korea and the National Research Foundation of Korea (NRF-2020S1A5A2A03044181).

Author contributions statement

HK, graduate student at Chungbuk National University, collected and analyzed data, and led manuscript preparation. HK is now a clinical psychology intern at Chonnam National University Hospital. SY, professor at Chungbuk National University, served as the principal investigator of the research grant and supervised the research process. All authors provided critical feedback, participated in revision of the manuscript, and approved the final submission.


References
1. An, J. Y., Seo, E. R., Lim, K. H., Shin, J. H., & Kim, J. B. (2013). Standardization of the Korean version of screening tool for depression (Patient Health Questionnaire-9, PHQ-9). Journal of the Korean Society of Biological Therapies in Psychiatry, 19, 47-56.
2. Anestis, M. D., Pennings, S. M., & Williams, T. J. (2014). Preliminary results from an examination of episodic planning in suicidal behavior. Crisis, 35, 186-192.
3. Anestis, M. D., Soberay, K. A., Gutierrez, P. M., Hernández, T. D., & Joiner, T. E. (2014). Reconsidering the link between impulsivity and suicidal behavior. Personality and Social Psychology Review, 18, 366-386.
4. Bae, S. M. (2019). The prediction model of suicidal thoughts in Korean adults using decision tree analysis: A nationwide cross-sectional study. PloS One, 14, e0223220.
5. Bagge, C. L., Littlefield, A. K., & Lee, H. J. (2013). Correlates of proximal premeditation among recently hospitalized suicide attempters. Journal of Affective Disorders, 150, 559-564.
6. Beck, A. T., Schuyler, D., & Herman, I. (1974). Development of suicidal intent scales. In A. T. Beck, H. L. Resnik, & D. J. Lettieri (Eds.), The prediction of suicide (45-56). Bowie, MD: Charles Press Publishers.
7. Beck, A. T., Weissman, A., Lester, D., & Trexler, L. (1974). The measurement of pessimism: The hopelessness scale. Journal of Consulting and Clinical Psychology, 42, 861-865.
8. Breiman, L., Friedman, J., Stone, C. J., & Olshen, R. A. (1984). Classification and regression trees. Boca Raton, Florida: CRC press.
9. Brugha, T., Bebbington, P., Tennant, C., & Hurry, J. (1985). The list of threatening experiences: A subset of 12 life event categories with considerable long-term contextual threat. Psychological Medicine, 15, 189-194.
10. Buchman-Schmitt, J. M., Chu, C., Michaels, M. S., Hames, J. L., Silva, C., Hagan, C. R., . . . Joiner Jr, T. E. (2017). The role of stressful life events preceding death by suicide: Evidence from two samples of suicide decedents. Psychiatry Research, 256, 345-352.
11. Chaudhury, S. R., Singh, T., Burke, A., Stanley, B., Mann, J. J., Grunebaum, M., . . . Oquendo, M. A. (2016). Clinical correlates of planned and unplanned suicide attempts. The Journal of Nervous and Mental Disease, 204, 806-811.
12. Conner, K. R. (2004). A call for research on planned vs. unplanned suicidal behavior. Suicide and Life-Threatening Behavior, 34, 89-98.
13. Crane, C., Shah, D., Barnhofer, T., & Holmes, E. A. (2012). Suicidal imagery in a previously depressed community sample. Clinical Psychology and Psychotherapy, 19, 57-69.
14. Dennis, J. P., & Vander Wal, J. S. (2010). The cognitive flexibility inventory: Instrument development and estimates of reliability and validity. Cognitive Therapy and Research, 34, 241-253.
15. Franklin, J. C., Ribeiro, J. D., Fox, K. R., Bentley, K. H., Kleiman, E. M., Huang, X., . . . Nock, M. K. (2017). Risk factors for suicidal thoughts and behaviors: A meta-analysis of 50 years of research. Psychological Bulletin, 143, 187-233.
16. Gonzalez, V. M., & Neander, L. L. (2018). Impulsivity as a mediator in the relationship between problem solving and suicidal ideation. Journal of Clinical Psychology, 74, 1626-1640.
17. Hamza, C. A., Willoughby, T., & Heffer, T. (2015). Impulsivity and nonsuicidal self-injury: A review and meta-analysis. Clinical Psychology Review, 38, 13-24.
18. Hausman, C., Meffert, B. N., Mosich, M. K., & Heinz, A. J. (2019). Impulsivity and cognitive flexibility as neuropsychological markers for suicidality: A multi-modal investigation among military veterans with Alcohol Use Disorder and PTSD. Archives of Suicide Research, 24, 313-326.
19. Heo, S. Y. (2011). Role of cognitive flexibility in the relationship between perfectionism and psychological maladjustment (Unpublished master’s thesis). Seoul National University, Seoul, Korea.
20. Holmes, E. A., Crane, C., Fennell, M. J. V., & Williams, J. M. G. (2007). Imagery about suicide in depression—“Flash-forwards”? Journal of Behavior Therapy and Experimental Psychiatry, 38, 423-434.
21. Joiner, T. E. (2005). Why people die by suicide. Cambridge, MA: Harvard University Press.
22. Kattimani, S., Sarkar, S., Rajkumar, R. P., & Menon, V. (2015). Stressful life events, hopelessness, and coping strategies among impulsive suicide attempters. Journal of Neurosciences in Rural Practice, 6, 171-176.
23. Kim, J., & Kim, K. (2018). Analysis on influence of triggering variables related the suicidal ideation, suicidal plan, and suicidal attempt: Focused on participants in 6th KoWePS. The Korea Contents Society, 18, 244-360.
24. Kim, S., Lee, E. H., Hwang, S. T., Hong, S. H., Lee, K., & Kim, J. H. (2015). Reliability and validity of the Korean version of the Beck Hopelessness Scale. Journal of Korean Neuropsychiatry Association, 54, 84-90.
25. Kim, J. M., Lee, H. J., Ju, G. W., Kim, S. C., Jeon, H. J., Park, G. J., … Lee, S. W. (2019). Analysis of risk factors affecting a suicidal attempter exposing suicidal intensions for the development of the active intervention strategy for suicide prevention. Journal of The Korean Society of Emergency Medicine, 30, 155-165.
26. King, K. M., Feil, M. C., & Halvorson, M. A. (2018). Negative urgency is correlated with the use of reflexive and disengagement emotion regulation strategies. Clinical Psychological Science, 6, 822-834.
27. King, M. W., & Resick, P. A. (2014). Data mining in psychological treatment research: A primer on classification and regression trees. Journal of Consulting and Clinical Psychology, 82, 895-905.
28. Ko, S., & You, S. (2020). Development and validation of the suicidal imagery questionnaire. Korean Journal of Clinical Psychology, 39, 1-14.
29. Lee, Y. R., & Park, K. H. (2017). The moderation effects of cognitive flexibility on the relationship between internet flow and internet addiction. Clinical Psychology in Korea: Research and Practice, 3, 95-117.
30. Lim, S. Y., & Lee, Y. H. (2014). A Korean validation of the UPPS-P Impulsive Behavior Scale in college students. Korean Journal of Clinical Psychology, 33, 51-71.
31. Lim, M., Lee, S., & Park, J. I. (2016). Differences between impulsive and non-impulsive suicide attempts among individuals treated in emergency rooms of south korea. Psychiatry Investigation, 13, 389-396.
32. Liu, R. T., & Miller, I. (2014). Life events and suicidal ideation and behavior: A systematic review. Clinical Psychology Review, 34, 181-192.
33. Mann, J. J., Ellis, S. P., Waternaux, C. M., Liu, X., Oquendo, M. A., Malone, K. M., . . . Currier, D. (2008). Classification trees distinguish suicide attempters in major psychiatric disorders: A model of clinical decision making. The Journal of Clinical Psychiatry, 69, 23-31.
34. May, A. M., & Klonsky, E. D. (2015). “Impulsive” suicide attempts: What do we really mean?. Personality Disorders: Theory, Research, and Treatment, 7, 293-303.
35. Millner, A. J., Lee, M. D., Buckholtz, J. W., Auerbach, R. P., & Nock, M. K. (2020). Are suicide attempters more impulsive than suicide ideators? General Hospital Psychiatry, 63, 103-110.
36. Millner, A. J., Lee, M. D., & Nock, M. K. (2017). Describing and measuring the pathway to suicide attempts: A preliminary study. Suicide and Life‐Threatening Behavior, 47, 353-369.
37. Nock, M. K., Borges, G., Bromet, E. J., Cha, C. B., Kessler, R. C., & Lee, S. (2008). Suicide and suicidal behavior. Epidemiologic Reviews, 30, 133-154.
38. O'Connor, R. C., & Nock, M. K. (2014). The psychology of suicidal behaviour. The Lancet Psychiatry, 1, 73-85.
39. Oh, E. S., Choi, J. H., Lee, J. W., & Park, S. Y. (2018). Predictors of intentional intoxication using decision tree modeling analysis: A retrospective study. Clinical and Experimental Emergency Medicine, 5, 230-239.
40. Posner, K., Brown, G. K., Stanley, B., Brent, D. A., Yershova, K. V., Oquendo, M. A., . . . Mann, J. J. (2011). The columbia–suicide severity rating scale: Initial validity and internal consistency findings from three multisite studies with adolescents and adults. American Journal of Psychiatry, 168, 1266-1277.
41. Rimkeviciene, J., O’Gorman, J., & De Leo, D. (2015). Impulsive suicide attempts: A systematic literature review of definitions, characteristics and risk factors. Journal of Affective Disorders, 171, 93-104.
42. Simon, T. R., Swann, A. C., Powell, K. E., Potter, L. B., Kresnow, M. J., & O’Carroll, P. W. (2001). Characteristics of impulsive suicide attempts and attempters. Suicide and Life-Threatening Behavior, 32, 49-59.
43. Spitzer, R. L., Kroenke, K., Williams, J. B., & Patient Health Questionnaire Primary Care Study Group. (1999). Validation and utility of a self-report version of PRIME-MD: The PHQ primary care study. JAMA, 282, 1737-1744.
44. Sohn, S. Y. (2014). Factors affecting suicidal ideation, suicidal plan and suicidal attempt in korean adolescents. Journal of the Korea Academia-Industrial Cooperation Society, 15, 1606-1614.
45. Spokas, M., Wenzel, A., Brown, G. K., & Beck, A. T. (2012). Characteristics of individuals who make impulsive suicide attempts. Journal of Affective Disorders, 136, 1121-1125.
46. Wang, Y., Sareen, J., Afifi, T. O., Bolton, S. L., Johnson, E. A., & Bolton, J. M. (2012). Recent stressful life events and suicide attempt. Psychiatric Annals, 42, 101-108.
47. Wei, S., Liu, L., Bi, B., Li, H., Hou, J., Chen, W., . . . Qin, X. (2013). Comparison of impulsive and nonimpulsive suicide attempt patients treated in the emergency departments of four general hospitals in Shenyang, China. General Hospital Psychiatry, 35, 186-191.
48. Wenzel, A., & Beck, A. T. (2008). A cognitive model of suicidal behavior: Theory and treatment. Applied and Preventive Psychology, 12, 189-201.
49. Wenzel, A, Brown, G. K. & Beck, A. T. (2009). Cognitive therapy for suicidal patients: Scientific and clinical applications. Washington, DC, American Psychological Association.
50. Whiteside, S. P., & Lynam, D. R. (2001). The five factor model and impulsivity: Using a structural model of personality to understand impulsivity. Personality and Individual Differences, 30, 669-689.
51. Wojnar, M., Ilgen, M. A., Czyz, E., Strobbe, S., Klimkiewicz, A., Jakubczyk, A., . . . Brower, K. J. (2009). Impulsive and non-impulsive suicide attempts in patients treated for alcohol dependence. Journal of Affective Disorders, 115, 131-139.
52. Wyder, M., & De Leo, D. (2007). Behind impulsive suicide attempts: Indications from a community study. Journal of Affective Disorders, 104, 167-173.
53. Xiao, Y., Chen, Y., Meng, Q., Tian, X., He, L., Yu, Z., & Wang, Y. (2019). Suicide ideation and suicide plan in Chinese left-behind children: Prevalence and associated factors. Journal of Affective Disorders, 257, 662-668.