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 Table of Contents  
Year : 2022  |  Volume : 43  |  Issue : 2  |  Page : 80-86

Relationships between suicide intention, cognitive styles, and decision making in attempted suicide

1 Department of Psychiatry, JSS Academy of Higher Education and Research, Mysuru, Karnataka, India
2 Department of Medicine (Psychiatry), College of Medicine, Shaqra University, Shaqra, Saudi Arabia

Date of Submission09-Jul-2021
Date of Decision30-Jul-2021
Date of Acceptance31-Aug-2021
Date of Web Publication24-Jun-2022

Correspondence Address:
Dushad Ram
College of Medicine, Shaqra University, Shaqra, Zip Code: 15526
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ejpsy.ejpsy_32_21

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Background This study suggests a link of suicidal intention with cognitive styles and decision making. There is a paucity of studies examining these relationships from a multidimensional perspective.
Aims This study aimed to examine the relationships of suicide intention, cognitive styles, and decision making in serious suicide attempts.
Participants and methods One hundred individuals with serious suicide attempts were assessed in this hospital-based cross-sectional study using sociodemographic and clinical questionnaires, the Mini-International Neuropsychiatric Interview-Plus (MINI-Plus), the Pierce Suicidal Intention Scale (PSI), the Melbourne Decision Making Questionnaire, and the Cognitive Style Inventory.
Results The common dimensions of cognitive styles were systematic, undifferentiated, and split. The PSI score was statistically significantly predicted by the vigilance (positive) and buck-passing scores in a linear regression analysis (negative). There were no significant relationships between the PSI score and cognitive styles. There was a statistically significant group difference in the Melbourne Decision Making Questionnaire vigilance score by systematic, undifferentiated, and split cognitive style dimensions in the Mann–Whitney U-test.
Conclusion Systematic, undifferentiated, and split cognitive styles are prevalent in serious suicide attempts. Rational decision making may be proportionate to the severity of suicide intent, but is constrained by the scarcity and static nature of cognitive style in attempted suicide.

Keywords: attempted suicide, cognitive styles, decision-making, suicide intention

How to cite this article:
Reddy S, Ram D. Relationships between suicide intention, cognitive styles, and decision making in attempted suicide. Egypt J Psychiatr 2022;43:80-6

How to cite this URL:
Reddy S, Ram D. Relationships between suicide intention, cognitive styles, and decision making in attempted suicide. Egypt J Psychiatr [serial online] 2022 [cited 2024 Mar 5];43:80-6. Available from: https://new.ejpsy.eg.net//text.asp?2022/43/2/80/348147

  Introduction Top

Every year, around 20 million people attempt suicide, and 1 million die (World Health Organization (2020)). The national rates are at 11.2 per 100 000 (Singh et al., 2016). Many demographic and clinical factors are linked to attempted suicide. An attempt has been made to study the underlying psychological factors such as mental pain, aggression, and communication difficulties (Gvion and Levi-Belz, 2018).

Decision making refers to the act of evaluating several alternatives and choosing the one most likely to achieve one or more goals and follow normative standards for rational decision making. It is determined by multiple psychological processes and factors (Sheftall et al., 2015; Tyburski, 2017). A recent meta-analysis reported alteration in decision making among suicide attempts (Perrain et al., 2021) and this is mediated by emotional dysfunction (Jollant et al., 2005), escape decision making (Millner et al., 2019), framing effect of past negative experiences (Szanto et al., 2015), psychiatric morbidities (Richard-Devantoy et al., 2016; Deisenhammer et al., 2018; Ponsoni et al., 2018), and family history of suicidal behavior (Hoehne et al., 2015). The neurocognitive vulnerability to suicidal behavior involves impaired decision making and cognitive control (Richard-Devantoy et al., 2013). Most studies used the Gambling Task test to assess decision- making, and few used a multidimensional decision-making assessment tool. Procrastination may positively relate to suicide proneness (Klibert et al., 2016), and a hypervigilance decision-making style correlates with rumination (Di Schiena et al., 2013).

Cognitive style is a person’s characteristic mode of perceiving, thinking, remembering, and problem solving (VandenBos, 2015). Many classifications exist for cognitive styles, but Martin’s Systematic, Intuitive, Integrated, Undifferentiated, and Split cognitive style dimensions are widely used (Martin, 1998).

Most studies on cognitive style used a negative/positive dichotomy in suicidality and concepts based on rumination tendency. Negative cognitive styles are linked to suicidal thoughts and behaviors (Abramson et al., 1998; Ellis, 2006; Kleiman et al., 2014; Stange et al., 2015) that may result in self-criticism (Stange et al., 2015), a dysfunctional attribution style (Rotheram-Borus et al., 1990), negative self-talk (Wolff et al., 2014), etc. We could not find any research on suicidality from Martin’s cognitive style perspective. Report suggests that split cognitive styles are better problem solver (Saxena et al., 2014) and systematic and undifferentiated styles limit the problem-solving ability and enhance bias (Martin, 1998) in nonsuicidal individuals. Problem-solving impairment is common in attempted suicide (McAuliffe et al., 2003; Pollock and Williams, 2004; Abdollahi et al., 2016), and problem solving is inversely related to suicidal thoughts (Sharaf et al., 2018).A possible link of serious suicide attempt with cognitive style (Beautrais et al., 1999) and rational decision making was reported (Qiu and Klonsky, 2021). Among nonsuicidal individuals, cognitive styles are congruent with decision making (Rosenberg, 2011; Rani, 2017; Qiu and Klonsky, 2021). Indirect evidence suggests that rational decision-making correlates with systematic and split types of Martin’s cognitive style dimension among nonsuicidal people (Rani, 2017). Due to the lack of research on the relationships of these variables in attempted suicide, this study was carried out. This study examined cognitive and decision-making styles on a multidimensional scale. The Melbourne Decision-Making Questionnaire (MDMQ), developed by Mann et al. (1997), assesses four dimensions of decision making: vigilance, hypervigilance, procrastination, and buck passing. The Cognitive Style Inventory (CSI) developed by Martin (1998) assesses four dimensions of cognitive style: systematic, intuitive, integrated, undifferentiated, and split. We hypothesized that vigilance decision making would positively link to the systematic cognitive style.

  Participants and methods Top

This cross-sectional hospital-based study was carried out at a Tertiary Care Center in south India, after obtaining approval from the Institutional Ethics Committee. One hundred individuals aged 18–65 years, of both sexes, admitted for serious attempted suicide and who survived were recruited within 15 days of the attempt, if they did not have a diagnosis of dementia and mental retardation, presence of psychotic symptoms, or attempt suicide during substance intoxication. For this study, serious attempted suicide was defined as any attempted suicide that requires hospitalization for more than 24 h and fulfills one of the following treatment criteria: (a) treatment in specialized units, including the ICU; (b) surgery under general anesthesia; and (c) extensive medical treatment, including antidotes for drug overdose, telemetry, or repeated tests or investigations. After obtaining informed consent, all participants were assessed using the following tools:
  1. Sociodemographic and clinical proforma: the proforma consisted of age, education, occupation, marital status, socioeconomic status, religion, mode of the attempt, any psychiatric diagnosis, previous or family history of suicide attempts, and any medical comorbidities.
  2. Mini-International Neuropsychiatric Interview-Plus (MINI-Plus): the MINI is a short structured diagnostic psychiatric interview that establishes the diagnosis of psychiatric disorders and the presence of suicidality as per the International Classification of Disease and Related Health Problems-10th edition or DSM-IV. It consists of 120 questions and focuses on the current diagnosis by assessing for Axis I disorders. Two to 4 questions to screen for each disorder are used. Additional questions on symptoms are asked only after the screen questions point to a particular disorder. It is easier for nonspecialized interviewers to administer MINI due to its structured nature. It takes around 15 min to conduct in patients. It can be used for a short structured psychiatric interview in research. Studies have shown good reliability and validity of the scale (Sheehanet al., 1998).
  3. Pierce Suicidal Intention Scale (PSI): David W. Pierce designed the suicide intent scale, with the main preference given to objectivity and the patient’s statement of intent. It has a maximum score of 21, with the following risk categories: score less than 4=low risk; 4–10 medium risk; and greater than 10 high risk of intentionality (Pierce, 1977). This scale includes 12 items under three headings: circumstance score − which consisted of isolation, timing, precaution against rescue, acting to seek help during the attempt, final act on anticipation of death, suicide note; self-report score such as lethality, stated intent, premeditation, reaction to act; and medical risk score such as the predicted outcome and death without medical treatment (Pierce, 1981). This scale has been used in the Indian population (Ramet al., 2012; Ramet al., 2016).
  4. MDMQ: the Melbourne decision-making questionnaire originally developed by Mannet al.(1997) was based on Jane and Mann’s conflict theory of decision making, and it has 22 items. Each question is scored as 0-not true for me, 1-sometimes true for me, and 2-true for me. The scale was later adopted and validated by Cotrenaet al.(2017), and one item each from the buck-passing and vigilance scale and two items from the hypervigilance scale were removed as it increased the reliability of subsequent subscales. Therefore, there are five questions for assessing vigilance, five questions for assessing Buck Passing, five questions for assessing procrastination, and three questions for assessing Hypervigilance (Mannet al., 1997). The questionnaire is used in the Indian population (Awasthi and Prabhakar, 2019; Gopal, 2020).
  5. CSI: the CSI is a self-administered scale consisting of 40 statements: 20 assess the systematic style and the remaining 20 assess the intuitive style (Martin, 1998). The patient answers each question by choosing the response best suited to him or her with the help of a Likert scale with the following responses: 1-strongly disagree, 2-disagree, 3-undecided, 4-agree, and 5-strongly agree. Responses to the questions yield a systematic score and an intuitive score, which can each be divided into high (>81), medium-high (71–80), medium-low (61–70), and low (<60). Both systematic and intuitive scores were used to assess the type of cognitive style. For this study, four dimensions were calculated as follows. systematic style: a high systematic score with a low intuitive score; Intuitive style: a high intuitive score with a low systematic score; Integrated style: a high systematic score with a high intuitive score; Undifferentiated style: a low Intuitive score with a low systematic score; and Split style: a medium systematic score with a medium intuitive score. This tool has been in use in the Indian population (Saxena, 2015; Rani, 2017).

Data were analyzed using the Statistical Package for Social Sciences (SPSS) [IBM Corp. (2015). IBM SPSS Statistics for Windows, version 23 (IBM Corp., Armonk, NY, USA]. The descriptive statistics including quantitative variables like mean and SD and qualitative variables like percentages and frequencies were calculated. Frequency distributions of categorical variables across two or more groups were determined using the χ2 test. To assess the relationships of the MDMQ score and PSI scores, linear regression analysis was used, while the Mann–Whitney U-test was used to assess the relationships of dimensions of cognitive style with PSI scores and MDMQ scores. α for significance for all inferences was set to P less than 0.05.

  Results Top

The majority of the population was in their early adulthood, educated, employed, and Hindu ([Table 1a]). The majority had no psychiatric or medical morbidities, no family history of suicide, the common method of suicide attempt had been poisoning, had high suicidal intent, and had less intuitive and integrated cognitive styles ([Table 1]b). The mean scores for vigilance, hypervigilance, procrastination, and buck-passing were 5.73, 3.49, 3.91, and 2.96, respectively ([Table 1b]).
Table 1 a: Sociodemographic characteristics

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Table 1 b: Clinical characteristics

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A linear regression analysis was performed to determine whether a score on the MDMQ dimension can predict the value of the PSI score. The model could explain 16% of variance (R2=0.161; d.f.=4; F=4.55; P=0.002). So far, MDMQ dimensions are concerned vigilance score statistically significant positively predicted the value of score on PSI (β=0.29; P=004), while buck-passing could statistically significant negatively predict the value of PSI score (β=−2.68; P=0.009) ([Table 2]). No statistically significant relationship was observed between different cognitive styles and scores on PSI ([Table 3]).
Table 2 Relationships between decision making and PSI scores

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Table 3 Relationships between cognitive styles and the PSI score

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A Mann–Whitney U-test was carried out to determine the relationships between decision making and cognitive styles. There was a statistically significant group difference on the score of the vigilance dimension of decision making for split [Mann–Whitney U-test (AMU)=470.50, Z=−4.39, P=0.001], undifferentiated (AMU=385.50, Z=−4.28, P=0.001), and systematic cognitive styles (AMU=359.00, Z=−4.49, P=0.001) ([Table 4]).
Table 4 Relationships between decision-making and cognitive styles

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  Discussion Top

Demographic and clinical characteristics are comparable to those described in a previous report from this geographic region (Ram et al., 2012; Ram et al., 2019; Ram et al., 2020), and to a certain degree, it reflects the population characteristics it caters services. Half of the participants in the study did not have a psychiatric diagnosis. In India, family issues are the main cause of suicide, followed by illness, and poisoning remains the most common method of suicide (Chiu, 1972; National Crime Records Bureau, 2019).

The most frequent cognitive style was split, followed by systematic and undifferentiated. This could be due to cultural influences (Chiu, 1972; Ferris et al., 2018; National Crime Records Bureau, 2019). These styles were reported to be prevalent among Indian students, although their prevalence could not be traced to individuals with attempted suicide (Srinivas, 2014; Sharma, 2017; Srinivas Kumar and Munichandra, 2017). MDMQ scores were reported in a similar manner among Indian students, as observed in this study (Gopal, 2020). In addition, some studies discovered a positive correlation between systematic and intuitive-cognitive styles with resilience (Bashir et al., 2013; Ahmed, 2015).

The severity of suicidal intention was positively predicted by rational decision-making (vigilance) and negatively predicted by avoidance decision making (Buck-passing). Links between cognitive style and decision making have been reported (Hunt et al., 1989; Thunholm, 2004; Qiu and Klonsky, 2021), and individual differences in decision-making style may partially be due to the differences in cognitive style (Andersen, 2000). Our finding partially corroborates Levenson and Neuringer’s observation that suicide is more prevalent in individuals with field-dependent cognitive styles (Levenson and Neuringer, 1974). The finding of the study contrasts with a previous report that rational decision making is less prevalent in attempters (Beautrais et al., 1999). This difference could be explained by the fact that all participants in this study were attempters of suicide. Another possibility is that impulsivity temporarily impairs rationality, leading to a suicide attempt, particularly in this study population, which may be restored following the attempt (Ram et al., 2019). There were no significant relationships between cognitive style and severity of suicide intention.

Consistent with our hypothesis, those with rational decision making (vigilance) tended to overutilize a few cognitive styles (systematic style) and underutilize multiple cognitive styles concurrently (split and) or were unable to utilize cognitive styles and remained passive and withdrawn (undifferentiated style). Martin asserted that systematic and undifferentiated styles may impede one’s ability to solve problems (Martin, 1998). This means that rational decision making is constrained more by the static nature of cognitive style functioning than by the dynamic nature of cognitive style functioning. As suggested by Sheehy and O’Connor (2002), this may result in cognitive inflexibility, associated cognitive processing dysfunction and cognitive distortion, and continued negative cognition. According to some reports, cognitive styles may obstruct decision making by distorting cognitive processing when moods change, as observed in this study (MacGillivray and Baron, 1994).

The findings of this study should be interpreted with caution, as they may apply to the tertiary care center. The limitations of this study were that there was no control group, and that it had a hospital-based and cross-sectional study design.

  Conclusion Top

In attempted suicide, some of Martin’s cognitive styles (systematic, undifferentiated, split) are common. Rational decision making may proportionately be linked to the severity of suicide intent and constrained by the limited and nondynamic nature of cognitive styles. The finding of this study implies that, for effective and rational decision making, psychological intervention may be needed to correct the abnormal pattern of cognitive styles.

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  [Table 1a], [Table 1b], [Table 2], [Table 3], [Table 4]


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