Decision-Making Competence and Attempted Suicide

Abstract

Objective The propensity of people vulnerable to suicide to make poor life decisions is increasingly well documented. Do they display an extreme degree of decision biases? The present study used a behavioral decision approach to examine the susceptibility of low-lethality and high-lethality suicide attempters to common decision biases, which may ultimately obscure alternative solutions and deterrents to suicide in a crisis. Method We assessed older and middle-aged individuals who made high-lethality (medically serious; N=31) and low-lethality suicide attempts (N=29). Comparison groups included suicide ideators (N=30), non-suicidal depressed (N=53), and psychiatrically healthy participants (N=28). Attempters, ideators, and non-suicidal depressed participants had unipolar non-psychotic major depression. Decision biases included sunk cost (inability to abort an action for which costs are irrecoverable), framing (responding to superficial features of how a problem is presented), under/overconfidence (appropriateness of confidence in knowledge), and inconsistent risk perception. Data were collected between June of 2010 and February of 2014. Results Both high- and low-lethality attempters were more susceptible to framing effects, as compared to the other groups included in this study (p≤ 0.05, ηp2 =.06). In contrast, low-lethality attempters were more susceptible to sunk costs than both the comparison groups and high-lethality attempters (p≤ 0.01, ηp2 =.09). These group differences remained after accounting for age, global cognitive performance, and impulsive traits. Premorbid IQ partially explained group differences in framing effects. Conclusion Suicide attempters’ failure to resist framing may reflect their inability to consider a decision from an objective standpoint in a crisis. Low-lethality attempters’ failure to resist sunk-cost may reflect their tendency to confuse past and future costs of their behavior, lowering their threshold for acting on suicidal thoughts.

Chronic Stress Alters Striosome-Circuit Dynamics, Leading to Aberrant Decision-Making

“…The abnormal cost-benefit integration indicated by the abnormal utility functions we observed suggests a parallel to human irrational choice behavior such as seen in choices of high risk (Aupperle and Paulus, 2010; Szanto et al, 2015), but the increase in high-cost/high-reward choices could have reflected a beneficial adaptation associated with surviving in extreme environments that previously evoked stress. ’Rational’ linear integration, as we saw in the non-stressed controls, could entail computational time and energy resources not required in sticking to the high-cost/high-reward decisions.…”

“…Abnormal decision-making, including risky or irrational choices leading to negative outcomes, can emerge as a symptom in neurologic and neuropsychiatric disorders, including anxiety and depression, bipolar disorder, Huntington’s disease, schizophrenia, and suicidality (Amemori and Graybiel, 2012; Aupperle and Paulus, 2010; Gleichgerrcht et al, 2010; Szanto et al, 2015). The development of such disorders can be facilitated by exposure to chronic stress (Pittenger and Duman, 2008; Selye, 1936); and prolonged stress can itself induce aberrant decision-making (Schwabe and Wolf, 2009; Soares et al, 2012; Sousa and Almeida, 2012).…”

Pathways to Late-Life Suicidal Behavior

“…Susceptibility to framing (responding to superficial features of how a problem is presented) was its defining characteristic, perhaps highlighting a distinct contribution of this factor 14 .…”

“…One pathway to suicide may thus be characterized by late-onset suicidal behavior where age-related cognitive decline or prodromal dementia 10-13 interact with dispositional and environmental factors. Another pathway maybe marked by decision-making deficits 14-16 seen in real life and in the laboratory in a subgroup of suicide attempters, accompanied by different levels of cognitive impairment 12, 15-21 and impulsivity.…”

“…We selected potential risk variables suggested by the Mann stress-diathesis model 4 as well as dispositional measures including interpersonal functioning 25 .We included measures of cognitive performance 17, 26 decision competence 14 , different facets of impulsivity 27-29 , and social support 30 .…”