Examining Mechanisms Underlying Suicidal Imagery and Near-term Fluctuations in Suicide Risk in Lab and in Daily Life

Emerging evidence suggests suicidal imagery, or mental visualizations related to killing oneself, is common among at-risk individuals and may be associated with elevated risk for suicidal thoughts and behaviors (STB).[1-3] However, suicidal imagery is rarely included in suicide risk measures and clinical evaluations, which may lead to inaccurate estimates and inadequate clinical care. Knowledge of suicidal imagery is limited due to the use of cross-sectional designs with limited clinical samples and a lack of consideration of STB risk factors (e.g., hopelessness, suicide capability). The proposed study will address these limitations by examining temporal fluctuations in suicidal imagery, its characteristics and precipitants, and dynamic associations with STB risk factors and risk for suicidal behaviors (SB) in daily life. The proposed study has three primary aims: 1) characterize suicidal imagery in daily life (e.g., vividness, content); 2) examine bidirectional associations between suicidal imagery and affect, and the temporal associations between suicidal imagery and STB risk factors, and SB; and 3) explore how affective and physiological responses to suicidal imagery influence short-term changes in suicide risk in daily life.

We will recruit a transdiagnostic sample of 75 adults (ages 18-65; 60% female) with clinically elevated suicide risk (active suicide ideation 2 or more times in one week or any SB in the past 4 months) and a history of suicidal imagery from the community via outpatient clinics, advertisements, and referral from collaborative studies. Exclusion criteria include psychotic disorders, intellectual disabilities, and medical conditions that may interfere with the ability to consent and complete study procedures (physiological data, ecological momentary assessment [EMA]).

Participants will complete two in-person visits, followed by a 21-day EMA protocol, to comprehensively assess momentary and short-term fluctuations in suicidal imagery, suicide risk, and STB risk factors. Visit 1 will include gold-standard interviews and self-report measures to capture lifetime and baseline suicidal imagery, suicide risk, and STB risk factors. Visit 2 will involve the Flash-Forward Suicidal Imagery Task to assess 1) subjective affective responses via visual analog scales (e.g., distress, vividness, comfort) and 2) physiological reactivity (heart rate variability, pre-ejection period, electrodermal activity) in response to personalized suicidal imagery. Per current guidelines, all participants will receive standardized risk assessments following Visit 2 and risk monitoring during EMA.

The proposed research aims to clarify the role of suicidal imagery in the development and maintenance of STB in daily life, particularly its unique role in risk for SB. Using a multi-modal approach that captures real-time affective and physiological responses to suicidal imagery in the lab and daily life, the results from the proposed study will provide valuable insights into how, when, and for whom imagery-related processes may exacerbate suicide risk. This research will directly inform suicide risk assessment approaches and guide the development of targeted interventions for SB (e.g., imagery-based cognitive therapies[4,5], imagery interference techniques[6], virtual reality-based interventions). Future research will investigate how adaptive interventions targeting suicidal imagery can reduce suicide risk and explore how individual differences in imagery characteristics and affective and physiological reactivity to suicidal imagery may influence treatment outcomes.