پریشانی های روانی و کمال گرایی در اقدام کنندگان به خودکشی: نقش بازداری رفتاری و فعال سازی

The present study explored the role of approach and avoidance motivation in a sample of recent suicide attempters. Specifically, it tested the hypotheses that perfectionism mediates the association between these different motivation systems and psychological distress (suicidal thinking & hopelessness). Patients (n = 125) admitted overnight following a suicide attempt completed self-report measures of motivation (BIS/BAS), socially prescribed perfectionism, depression/anxiety, hopelessness and suicidal thinking. The results showed that socially prescribed perfectionism mediated the relationship between behavioural inhibition (BIS) and suicidal thinking. In addition, in support of the updated Reinforcement Sensitivity Theory we found a moderating relationship between BIS and BAS-Drive in the prediction of hopelessness. The clinical and theoretical implications are discussed.

Suicide is a major cause of premature mortality, and therefore represents a social and health issue of prime importance. Increasing our understanding of such a significant public health issue is important, but the process has been hampered by the complex and often multi-faceted nature of suicide. Theoretical approaches to suicide have highlighted a number of vulnerability factors for suicide; however, a shared idea is that unbearable psychological pain is the common stimulus in suicidal behaviour (e.g., Baumeister, 1990 and O’Connor, 2011). That is, suicidal behaviour is reactive in as far as it represents an attempt to escape unbearable pain and negative self-awareness in which hopelessness is a frequent feeling (e.g., O’Connor, Fraser, Whyte, MacHale, & Masterton, 2008). Perfectionism, which is seen to be a stable personality trait, has been hypothesised to play a significant contributory role in increasing perceptions of psychological pain (e.g., Flamenbaum & Holden, 2007), and has consistently been linked to suicide (see O’Connor, 2007 for a review of the suicide and perfectionism relationship). 1.1. Perfectionism and suicidal thinking Interest in perfectionism has grown with the evidence that it plays an important role not only in the development, but also in the maintenance, of a variety of psychological and health problems. However, to allow research in this area to move forward and be incorporated successfully into a treatment setting, clarification on three distinct, but related issues is necessary. Firstly, a continued debate about the nature of perfectionism in terms of how many dimensions it contains has led to the development of a number of different models, most of which emphasise a multidimensional approach to the construct whereby both intra-personal and interpersonal factors should be included (e.g., Frost et al., 1990 and Hewitt and Flett, 1991). Secondly, with the emergence of these multi-dimensional models, research has started to highlight inconsistencies in the previously hypothesised purely maladaptive function of the trait, and indeed, some studies have emphasised an adaptive role for some perfectionism dimensions (e.g., O’Connor & O’Connor, 2003). Finally, as an extension to the last two points, there is therefore a growing need for research which attempts to explain the mechanisms that underpin the relationship between the perfectionism dimensions and psychological distress. This study attempts to investigate the final goal by examining the motivational background of multidimensional perfectionism. Perfectionism is often conceptualised as the chronic setting and striving for unrealistically high goals, and focussing on flaws in achieving these goals. One multi-dimensional approach to perfectionism was proposed by Hewitt and Flett (1991)1, who argued that perfectionism is made up of three distinct dimensions, one intra-personal (self-oriented perfectionism) and two inter-personal dimensions (other-oriented and socially prescribed perfectionism). Self-oriented perfectionism concerns the specific standards we set for ourselves. Socially prescribed perfectionism is associated with a fear of failure, and is related to the excessive standards we believe significant others expect of us, and other-oriented perfectionism concerns the high standards we expect of others. Overall, research findings have consistently shown that socially prescribed perfectionism is strongly associated with distress and suicidal thinking (O’Connor et al., 2009 and Rasmussen et al., 2008). In contrast, the research looking at other perfectionism dimensions is much less consistent. In a recent systematic review of the literature (O’Connor, 2007) it was suggested that self-oriented perfectionism may contain both maladaptive and adaptive constituents, and the extent to which this dimension is associated with negative or positive outcomes may depend on other characteristics of the individual. For example, it is generally acknowledged that perfectionism is an achievement-based construct which is strongly influenced by sensitivity to reward and punishment, and therefore, it is possible that the motivational issues may explain these differences. However, to date, little research has investigated the motivational background to trait perfectionism. 1.2. Understanding the motivational basis of perfectionism A considerable body of research has demonstrated that innate motivational systems govern appetitive and aversive behaviours (e.g., Brenner, Beauchaine, & Sylvers, 2005). Much of this research is based around the Reinforcement Sensitivity Theory (RST) proposed by Gray (1982) which suggests that we possess a behavioural activation or approach system (BAS) which controls our appetitive behaviours in response to signs of reward, and a behavioural inhibition system (BIS) which oversees risk assessment and defensive avoidance behaviours in response to competing motivational goals in the face of punishment and failure. More recently the RST has been revised to account for past discrepancies (rRST; e.g., Corr, 2001, Corr, 2008 and Jackson, 2003), and now suggests that three major motivation systems exist: BAS, BIS (underlies anxiety) and the fight-freeze system (FFFS; underlies fear). In addition, the model posits that BIS and BAS may interact in situations of conflict. More specifically, according to Gray and McNaughton (2000) the main purpose of BIS is to resolve conflict by either escaping the situation or by activating the BAS system (thereby approaching the conflict). In relation to perfectionism more specifically, Slade and Owens (1998) proposed a dual model of perfectionism which suggests that positive perfectionism is underpinned by the pursuit of excellence (i.e. approach) whereas negative perfectionism is underpinned by attempts to avoid failure (i.e. inhibition or escape). Consequently, the authors argued that the emotional consequences of these behaviours will also be different. This idea is supported by a study by O’Connor and Forgan (2007) which investigated the relationship between the behavioural inhibition and activation systems and perfectionism in the prediction of suicidality in a student sample, and found a clear relationship between suicidality and behavioural inhibition. More specifically, they found that higher levels of behavioural inhibition, that is, sensitivity to signals of punishment, were positively related to suicidal thinking. This finding confirms the importance of performance related motivations in social perfectionism: The habitual need to please others and to avoid punishment impairs constructive thinking and is the result of a motivational deficit and irrational beliefs (Mills & Blankstein, 2000). This is consistent with theoretical work in the motivational literature (rRST; Corr, 2004) and in the suicide literature (Integrated Motivational–Volitional Model (IMVM); O’Connor, 2011). 1.3. The present study We recruited patients who had been admitted to hospital following a suicide attempt, and measured their psychological well-being, perfectionism and motivational style. We focussed specifically on socially prescribed perfectionism as a recent systematic review of the suicide and perfectionism literature (O’Connor, 2007) which showed that, out of the three perfectionism dimensions, only socially prescribed perfectionism was consistently associated with suicide risk. We were particularly interested in self-reported threat and reward sensitivities (i.e., BIS/BAS) in this population as these motivational systems may control the intensity with which individuals respond behaviourally and affectively, and thus, may be implicated in suicide behaviour. With this in mind, the purposes of this study were threefold: (a) to examine the relationship between BIS/BAS and suicidal ideation/hopelessness (i.e. distress), (b) to test the relationship between BIS/BAS and perfectionism and (c) to test for mediating relationships between BIS/BAS and perfectionism in the prediction of distress. This relationship is of particular theoretical interest given that sensitivity to defeat and punishment is hypothesised to be implicated in increased risk of suicidal behaviour (O’Connor, 2011). Finally, on the basis of the revised RST (rRST) we were also interested in whether BIS and BAS interacted in suicide attempters as it can be argued that they are currently immersed in a conflict situation (death vs. living). We did not hypothesise any distinction between BIS and the fight-flight-freeze system (FFFS) as suggested in the rRST, as the Carver and White (1994) measure of BIS/BAS included in the current study was developed on the basis of the original RST (Gray, 1982). In relation to behavioural inhibition (BIS), and based on previous research, we hypothesised that BIS, but not the BAS sub-dimensions, would be significantly associated with distress (Hypothesis 1). In addition, given that socially prescribed perfectionism is characterised as a predominantly maladaptive personality trait which is associated with a fear of failure, we hypothesised that it would be positively associated with BIS motives (Hypothesis 2). We also hypothesised that BIS’s effect on distress would be mediated via socially prescribed perfectionism (Hypothesis 3). In relation to the potential interaction between the BIS/BAS systems, and based on recent research showing that during approach avoidance conflicts BAS-Drive moderates the relationship between BIS and conflict response (Berkman, Lieberman, & Gable, 2009), we tentatively hypothesised that BAS-Drive would also interact with BIS in the distress experienced by suicide attempters (Hypothesis 4).