Assessment of self-harm risk using implicit thoughts.

Abstract

Assessing for the risk of self-harm in acute care is a difficult task, and more information on pertinent risk factors is needed to inform clinical practice. This study examined the relationship of 6 forms of implicit cognition about death, suicide, and self-harm with the occurrence of self-harm in the future. We then attempted to develop a model using these measures of implicit cognition along with other psychometric tests and clinical risk factors. We conducted a prospective cohort of 107 patients (age > 17 years) with a baseline assessment that included 6 implicit association tests that assessed thoughts of death, suicide, and self-harm. Psychometric questionnaires were also completed by the patients, and these included the Beck Hopelessness Scale (Beck, Weissman, Lester, & Trexler, 1974), Barratt impulsiveness scale (Patton, Stanford, & Barratt, 1995), brief symptom inventory (Derogatis & Melisaratos, 1983), CAGE questionnaire for alcoholism (Ewing, 1984), and the drug abuse screening test 10 (Skinner, 1982). Medical and demographic information was also obtained for patients as potential confounders or useful covariables. The outcome measure was the occurrence of self-harm within 3 months. Implicit associations with death versus life as a predictor added significantly (odds ratio = 5.1, 95% confidence interval [1.3, 20.3]) to a multivariable model. The model had 96.6% sensitivity and 53.9% specificity with a high cutoff, or 58.6% sensitivity and 96.2% specificity with a low cutoff. This scale shows promise for screening emergency department patients with mental health presentations who may be at risk for future self-harm or suicide.

Life is Good, But Death Ain’t Bad Either: Counter-Intuitive Implicit Biases to Death in a Normative Population

“…This study therefore tests the assumption made with previous research, whether explicitly or implicitly, that normative participants do indeed demonstrate specific "self-life" and/or "selfnot-death" biases (i.e., Dickstein et al, 2015;Harrison, Stritzke, Fay, Ellison, & Hudaib, 2014;Nock et al, 2010;Price, Nock, Charney, & Mathew, 2009;Price et al, 2014;Randall et al, 2013;Tang, Wu, & Miao, 2013;Violanti, Mnatsakanova, & Andrew, 2013). Participants completed both a death-identity IAT and a death-identity IRAP that was created from the same stimuli.…”

“…The Implicit Association Test (Greenwald et al, 1998) is a computer-based test that assesses reaction time biases. The current study employed the deathidentity stimulus set developed by Nock and colleagues (2010) that has been employed in multiple previous studies (e.g., Dickstein et al, 2015;Harrison et al, 2014;Price et al, 2014Price et al, , 2009Randall et al, 2013;Tang et al, 2013;Violanti et al, 2013). One small modification was made to the stimulus set: due to ethical constraints on asking university students about suicide, and in order to assess attitudes to death generally rather than suicide specifically, the stimulus "suicide" was substituted for the word "death".…”

“…When IAT D scores were binarized using zero as a cutoff score, as employed by previous research (Nock et al, 2010;Randall et al, 2013), 32 participants were shown to have overall "self-life/others-death" effects (i.e., D scores ≤ 0) and 7 participants were shown to have overall "self-death/others-life" effects (i.e., D scores > 0). The majority of the sample (82%) therefore demonstrated effects on the IAT that were consistent with what previous research has classified as low risk of attempted suicide or self-harm, as might be expected within a normative sample.…”

“…While previous research on implicit attitudes to death has explored the associations between the concepts of (a) self and evaluation (i.e., "self-esteem": Creemers, Scholte, Engels, Prinstein, & Wiers, 2013;Dickstein et al, 2015;Franck, De Raedt, Dereu, & Van den Abbeele, 2007;Glashouwer et al, 2010;Price et al, 2009;Price et al, 2014); and (b) self and death (i.e., "death-identity": Dickstein et al, 2015;Harrison et al, 2014;Nock et al, 2010;Price et al, 2009;Price et al, 2014;Randall et al, 2013;Tang et al, 2013;Violanti et al, 2013); no work has explored the association between death and evaluation. This is somewhat surprising, given the centrality of evaluations within many psychological theories that focus on death.…”

Measuring implicit attitudes: A positive framing bias flaw in the Implicit Relational Assessment Procedure (IRAP).

“…The IAT has shown promise in predicting self-harm (Randall, Rowe, Dong, Nock, & Colman 2013), social anxiety disorders (Teachman & Allen, 2007) and suicidal ideation (Harrison, Stritzke, Fay, Ellison, & Hudaib, 2014). The current study questions the validity of a recently developed implicit measure, the Implicit Relational Assessment Procedure (IRAP; BarnesHolmes, Barnes-Holmes, Stewart, & Boles, 2010a), which has also been used with vulnerable populations.…”