Editorial

Editorial
Will New Insights Into Neural Networks
Help Us to Improve Our
Models of Suicidal Behavior?
Konrad Michel
University Hospital of Psychiatry, Bern, Switzerland
Suicide is a complex phenomenon, and we have learnt that
there is no simple cause–effect relationship that can explain
why people take their own lives. However, in recent
years research has provided us with new insights into biological
and psychological mechanisms related to suicidal
behavior. In a recent Crisis editorial, Kees van Heeringen
(2014) gave a fascinating overview of brain imaging studies
of suicidal behavior. Suicidal behavior is associated
with structural changes in cortical areas of the brain. For
instance, there is an intriguing study by Benedetti and colleagues
(2011) who, in patients with past suicide attempts,
found reduced gray matter volume in the dorsolateral prefrontal
cortex, orbitofrontal cortex, anterior cingulate, and
the basal ganglia – and that lithium treatment reversed
the loss of volume in these areas. Besides cortical abnormalities,
white matter abnormalities have been reported
(Mahon, Burdick, Wu, Ardekani, & Szeszko, 2012). van
Heeringen argues that in order to understand the neural
correlates of dysfunctional cognitive-emotional processing,
we need to go beyond simple structural brain abnormalities,
and focus on networks that connect frontal cortical
areas, including the cingulate cortex and subcortical
areas. The rationale is that connections and networks may
provide the key to the understanding of the neural and psychological
mechanisms involved in getting people to the
point of killing themselves.
The question then will be which clinical and psychological
concepts of suicidal behavior could be related to
such neural networks?
Decision Making
There is now a vast body of literature about decision making
in general and in suicidal individuals in particular, with
some of the studies including brain activation related to
decision making. Individuals with a history of suicidal
behavior, especially those with violent attempts, perform
significantly worse in the Iowa Gambling Task when compared
with healthy individuals (Jollant et al., 2005), and
they have difficulties in deciding between safe and risky
outcomes, particularly under conditions of uncertainty
(Jollant et al., 2010). Suicidal and depressed individuals
show greater interference in the emotional Stroop task
(Becker, Strohbach, & Rinck, 1999), a finding that is associated
with hypersensitivity to certain emotional stimuli,
which interfere with the neural processing involved
in inhibitory control tasks (Cha, Najmi, Park, Finn, &
Nock, 2010; Hu, Liu, Weng, & Northoff, 2012; Williams,
Mathews, & MacLeod, 1996). Stroop task performance involves
a fronto-cingulate network, more specifically, the
dorsal anterior cingulate cortex and the ventrolateral prefrontal
cortex (Wagner et al., 2013).
From Decision to Action
Patients describe suicidal acts as automatic, as “feeling
right,” even leading to inner calmness. In a long-term perspective
of a person’s life, however, suicide in most cases
appears as “taking action but taking the wrong action”
(Baumeister & Heatherton, 1996; Hines & Reidenberg,
2013). In the conceptual frame of dual processing theory
(Epstein, Pacini, Denes-Raj, & Heier, 1996; Evans, 1996;
Stanovich & West, 2000) intuitive and automatic behavior
is seen as typical for “System 1” processing. This processing
system, which is considered to operate with little or no
conscious input, is seen as the source of most of our actions.
Although usually reliable in familiar situations, with
generally swift and appropriate responses to challenges,
this computational system is subject to systematic errors
in specific circumstances. It typically operates within an
emotional context and has a tendency to jump to conclusions
on the basis of very limited evidence (Kahneman,
2012). In dual processing theory, System 2 has the function
of an override system for some of the risky decisions
© 2014 Hogrefe Publishing Crisis 2014
DOI: 10.1027/0227-5910/a000272

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Editorial
provided by System 1 – such as planning and initiating
suicidal behavior. The theory implies that in suicidal individuals
this correctional mechanism does not stop the
System 1 suicidal action. Switching of strategies as part
of decision-making processes has been related to a network
involving the medial and lateral prefrontal cortex and
the anterior cingulate cortex (Carter, Botvinick, & Cohen,
1999; Nee, Kastner, & Brown, 2011; Paulus et al., 2001).
The latter is involved in detecting situations that require
increased cognitive control (Botvinick, 2001).
Psychological Pain and Dissociation
Suicide attempters usually indicate that a predominant
motive for suicidal behavior was to end unbearable psychological
or mental pain (Orbach, Mikulincer, Gilboa-
Schechtman, & Sirota, 2003; Shneidman, 1993). There is no
generally agreed definition of psychological pain (Habenstein,
Reisch, & Michel, 2013; Tossani, 2013). Bolger
(1999) defined emotional pain as a state of “feeling broken”
that involved the experience of being wounded, with
a loss of self. In the Orbach & Mikulincer Mental Pain
Scale (Orbach, Mikulincer, Sirota, & Gilboa-Schechtman,
2003[author: correct ref?]) the main factors were a sense
of irreversibility and loss of control. Due to its state character,
psychological pain is not easily amenable to neuroimaging
(Meerwijk, Ford, & Weiss, 2013). A functional
magnetic resonance imaging study on mental pain using
script-driven recall of the suicidal crisis suggested a deactivation
in frontal cortical areas (BA 46, 10, 6) during the
mental pain mode, with increasing neural activity in the
medial prefrontal cortex and the anterior cingulate cortex
when patients were asked to recall how they acted on the
suicidal impulse (Reisch et al., 2010). Pain and emotion
processing is thought to involve interactions in subregions
of the cingulate gyrus associated with emotional memories,
autonomic control, and response selection – i.e.,
avoidance behavior – with the amygdala and prefrontal
regions (Price, 2000; Shackman et al., 2011; Vogt, 2005).
The Suicidal Self
In an action theoretical view, suicide emerges as a goal
when important life-career goals are jeopardized due to
negative experiences (Michel & Valach, 1997). The concept
of suicide as “escape from self“ (Baumeister, 1990)
encompasses negative attributions about the self, for example,
self-blame, guilt, and self-hate, following the awareness
of the self as falling short of important standards. A
central element is the deconstructed awareness of the self,
replacing the integrative and meaningful awareness of self
as an identity. Phenomenologically, the self is characterized
by certain typical properties, such as self-agency, self-coherence,
self-history (autobiographical self), and continuity
of the self (Kircher & David, 2003). Central to the self-
Crisis 2014
memory system is the working self (Conway, Pleydell-
Pearce, Whitecross, & Sharpe, 2003). The working self
creates a model of the psychological present based on the
autobiographical knowledge base (the long-term self),
and operates processes that initiate and monitor goaldirected
activity. Self-reflective properties are attributed
to the brain’s ability to access simultaneously information
concerning the personal past, present, and future (Ingvar,
1985). In suicidal individuals a tendency to overgeneral
memory retrieval, rather than recalling specific events, has
been found (Williams et al., 2007), resulting in impaired
problem-solving capacities. Neurobiologically, functions
associated with the working self have been related to a network
involving the prefrontal cortex, the striatum, and the
dorsal parietal cortex (Keenan, Wheeler, Gallup, & Pascual-Leone,
2000).
The Suicidal Mode
Patients’ descriptions of the suicidal state of mind as acute
and time-limited have been conceptualized as suicidal
mode. A threat mode includes autonomic arousal, along
with motor and sensory system activation, which orients
the individual for action such as fight or flight (Beck, 1996).
Triggers may be external or internal events. The concept
of the suicidal mode is related to acute stress conditions,
and is characterized by its on/off mechanism of changes in
cognition, affect, and behavior (Rudd, 2000). Dissociative
symptoms such as emotional numbing, detachment from
body, and indifference to physical pain are frequent in the
acute suicidal state of mind (Orbach, 1994). Dissociative
symptoms are a typical feature of PTSD symptomatology
and have been related to changes in neural activation
in the medial prefrontal and the anterior cingulate cortex
(Bremner et al., 1999; Lanius et al., 2001).
Is There Light at the End of the Tunnel?
The stress–diathesis model (Mann & Arango, 1992) has set
the frame to incorporate illness/psychosocial and biological
factors relevant for suicidal behavior. We have a fairly
good picture of genetic and epigenetic effects, associated
with functional and structural changes in brain areas involved
in emotion regulation and decision making as trait
factors (Turecki, Ernst, Jollant, Labonte, & Mechawar,
2012). The challenge will now be to improve our models
of suicidal behavior by linking and integrating neural, neuropsychological,
and psychological findings, which then
need to be translated into clinical suicide prevention. For
instance, a first implication of an integrated model could
be that even the best treatment cannot “cure” suicidality
after attempted suicide, because – and this should be
included in the patients’ psychoeducation – the suicidal
mode will be saved as contextual memory related to a neurobiological
mode, which can be triggered again any time
© 2014 Hogrefe Publishing

Editorial 3
in the future. Patients must be aware of this risk. Furthermore,
therapists – as well as patients – should take into
account that impaired cognitive functioning and decision
making in emotionally stressful situations is a long-term
trait, which will persist after the resolution of a suicidal
crisis – and that there is a neurobiological basis to this. We
could even imagine that education of the public about suicide
will in future move away from the mantra of equating
suicide with depression, and rather focus on suicide as the
serious result of an emotionally driven error of decision, a
decision taken in a moment of a temporary myopia for a
person’s long-term perspective. Perhaps we need an author
who launches a suicide-related bestseller like Kahneman’s
Thinking Fast and Slow (2012)[author: change ok?].
Certainly, Maris’s statement, “Suicide cannot be prevented
until it is properly conceptualized” (Maris, 1981), still
holds true. But at least it seems that we are getting closer.
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Accepted nnn, 2014
About the author
Konrad Michel, MD, is affiliated with the University of Bern, and
working in private practice. His main research interest is focused
on clinical suicide prevention, in particular on patient-oriented
models of suicidal behavior, and the therapeutic relationship in
the treatment of suicidal patients. He is the founder of the biennial
Aeschi Conferences.
Konrad Michel
Suicide Research Group
University Hospital of Psychiatry
Murtenstrasse 21
3010 Bern
Switzerland
Tel. +41 31 632-8811
Fax +41 31 632-8950
E-mail konrad.michel@spk.unibe.ch
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