1

Chapter 1

Introduction

Suicide is a leading cause of death worldwide, killing more than 800000

people each year (WHO,2014). One of the leading causes of death around the

world is suicide. Specifically, suicide is the third leading cause of death

among young adults 15 to 24 years old in the world. In 2013 suicide was the

second leading cause of death among person aged 15-24 years, the eighth among

person aged 55-64.

The increasing rate of suicide and suicidal attempt is a growing health

problem worldwide. In 2003, the rate of suicide completers was 25.2 per

100,000 in Korea.The suicide mortality rate reported in 2003 was 137% higher

than that reported 10 years earlier, and suicide was the 2nd leading cause of

mortality, particularly among youths aged 15 to 19 years.

The reduction of suicide is a public health priority for both the UK and

US governments

(Dept. of Health, 2002; US Public Health Service, 1999) and past suicidal

behavior is the best predictor of completed suicide (O’Connor & Sheehy,

2000). Consequently, research aimed at reducing the incidence of suicide often

focuses on individuals who engage in suicidal ideation or suicidal behavior to

help identify predictors of completed suicide.

 2

Suicide refers to the act or an instance of taking one’s own life

voluntarily and intentionally especially by a person of years of discretion

and of sound mind. Over 90 percent of people who die by suicide have a mental

illness at the time of their death. The most common mental illness is

hopelessness and depression.

Suicide in Pakistan has been a long term social issue and is a common

cause of unnatural death. Incident of suicide are often reported in the press

and newspapers throughout the country as well as by several non-governmental

organizations. In recent years, incidences of suicide appear to have increased

in Pakistan and suicide has become a major public health problem. Mental

illness is rarely mentioned. Lack of resources, poorly established primary and

mental health services and weak political processes make suicide prevention a

formidable challenge in Pakistan.

Suicide is the third leading cause of death among Americans aged 15 to

24 and is the eleventh leading cause of death among all Americans (Anderson &

Smith, 2003; Kessler, Borges & Walters, 1999).

Some people die by suicide because of depression and thus they may not

appear to be undergoing any negative life experiences yet still become

depressed and may die by suicide. Hopelessness another factor that leads to
 3

the suicide. Minkoff found that the intensity of suicidal intent was more

highly correlated with hopelessness than with depression.

There have been many reports of significant increasesin suicide and

suicide attempts in adolescents (Holinger & Offer, 1981; National Center for

Health Statistics, 1968-1991). Some authors have observed that suicide among

adolescents has reached epidemic proportions (Woznica & Shapiro, 1990) and

estimates indicate that at least five teenagers in the United States kill

themselves each day (Shaw, Sheehan, & Fernandez, 1987), with a total of 2,000

adolescents taking their lives each year (Shaffer, Garland, Gould, Fisher, &

Trautman, 1988). This rate has increased, with indications that suicide among

adolescents has tripled in recent years (Alcohol, Drug Abuse, and Mental

Health Administration, 1989). This trend in suicide behavior has given rise to

an urgency in attempting to understand the nature and prediction of the risk

factors involved ( Berman & Jobes, 1991; Brent, 1987).

Others investigators have supported the positive relationship among

hopelessness, depression, and suicidal intent in attempters.

Suicide and cognitive vulnerabilities:

Diathesis-stress models are founded on the premise that predisposing

(cognitive) vulnerabilities, when activated by stress, predict suicidal

behavior. To this end, a number of vulnerabilities have been identified in the

 4

psychopathology literature, including hopelessness (Beck, Steer,Kovacs &

Garrison, 1985), dichotomous thinking (Litinsky & Haslam, 1998), impaired

problem solving (Pollock & Williams, 2004), overgeneral autobiographical

memory (Williams, 1996), impaired positive future thinking (O’Connor., 2004)

and perceived burdensomeness (Joiner, Pettit, Walker, Voelz, Cruz, Rudd, &

Lester, 2002). However, this review will focus on one such vulnerability

factor. Thus understanding the risk factors for suicide and suicidal ideation

is very important for mental health professionals. Suicidal behavior occur in

response to interaction between biological psychological and socio

environmental risk factors along with the relative absence of protective

factors. Most studies suggested to elicit the risk factors for suicide for

example;those involving psychological autopsies have focused on the evaluation

of pathological mental status or psychiatric disorders as potential risk

factors. Information about the social and environmental correlates for suicide

is relatively scarce. There is continuing debate over the relative importance

of socio environmental factors in explaining suicidal behavior.

 5

Causes of suicide:

Cole, walter, Demaso, Kliegman, Behrman provide these causes & symtoms.

 The death of a loved one

 A divorce

 A serious loss

 A serious illness

 Loss of hope

 Being victimized

 Sexual abuse

 Physical abuse

 Alcohol abuse

 Inability to deal with a perceived failure

 Feeling of not being accepted by family,friends,or society

 Low self esteem

 .Breakup of family relationships

 Depression

 Broken love affairs

 Economic and Business affairs that turn sour

 Disfiguring injuries or disease

 Previous suicide attempts

 Being socially isolated or a victim of bullying

 6

 Being exposed to suicidal behavior

 Family history of suicide

 Childhood abuse and trauma

 Difficult seeking help or support

 Exposure to suicidal behavior

Sign and symptoms of suicidal behavior:

 Feel hopeless

 Feel trapped

 Feel alone

 Feel anxious or agitated

 Feel as if there is no reason to go on living

 Think of suicide as way out

 Experience mood swings

 Making a will or giving away personal possessions

 Searching for a means of doing personal harm, such as buying a gun

 Sleeping too much or too little

 Eating too little or eating too much

 Avoiding social interaction with others

 Expressing rage or intentions to seek

 Engaging in reckless behavior

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 8

Types of suicide:

Stark, Rodney & William Sims Bainbridge, 1996 provide these types.

Egoistic suicide:

People who would be most likely to commit this type of suicide feel

extremely deteched from their community. They do not a part of the greater

whole or a sense of belonging.

Fatalistic suicide:

People who commit this type of suicide feel oppressed by the society

around them. They feel constantly repressed, both physically and mentally, by

those who enforce power over them.

Anomic suicide:

This type of suicide is typical of people who feel morally lost and have

no sense of direction in their lives.

Altruistic suicide:

This type of suicide happens when a group or society has very

influential power over individuals. This is also associated with soldiers who

go to war for their country and run into the line of fire for their country’s

good.
 9

Treatment of suicide:

 Talk therapy

 Medication

 Lifestyle changes

 Avoiding alcohol and drugs

 Exercising regularly

 Sleeping well

 Family support and education

Hopelessness

Hopelessness refers to having no expectation of good or success.

Hopelessness can happen when someone is going through different times or

painful experiences or onemight feel hopeless without a specific reason.one

might feel overwhelmed, trapped or insecure or one might have a lot of self-

doubt. Many variables contribute with hopelessness such as depression,

anxiety, low level of self esteem, rumination, experienced by the people who

attempt suicide. Extreme Hopelessness is a cognitive distortion characterized

by the perceived absence of personal control over future events and

expectations that one will fail or encounter negative consequences in the

future. Hopelessness has been found to be an even stronger predictor of

suicidal behavior than depression and the best predictor of eventual completed
 10

suicide in adult populations. The role of hopelessness in clinical samples of

adolescents is less clear, with some studies reporting stronger relationships

with suicidal ideation than others. One might think that challenges are

insurmountable or that there are no solution to the problems you are facing.

Hopelessness might be a sign that you are depressed or that one may be on one

way toward depression. Sometimes hopelessness can lead to thoughts of wishing

one could go to sleep and not wake up or to plan to harm one’sself and end

one’slife. Person may not shared her&her feelings of hopelessness or thoughts

of harming yourself with others.

Psychological distress is frequently observed in patients during the

clinical course of this disease. Patients are confronted with problems such as

fear of death, unresolved issues, parting with family, and pain (Grumann and

Spiegel, 2003; Song, 2003; Taylor, 2003). Feelings of depression is a common

psychiatric disorder in suicidal patients, while hopelessness has been

associated with depression (Jones, Huggins, Rydall , Rodin (2003). , Okamura

., 2005). In the hopelessness theory of depression, Abramson hypothesized that

when negative life events occur, a lack of social support may lead to

increased hopelessness and thereby, to the onset of a syndrome referred to as

hopelessness depression (Abramson , Metalsky , Alloy ,1989). Feelings of

hopelessness are common reactions of patients.

 11

Hopelessness is also characterized by persistently negative feelings and

expectations about the future as well as loss of motivation. A sense of

hopelessness seems to lead to increasingly negative evaluations of new

situations and less effective coping strategies; thus, the perception is that

one will not accomplish anything meaningful (Avci., 2009). Both depression and

hopelessness are risk factors for suicidal ideation and suicide patients who

are depressed may also have physical symptoms which are difficult to palliate

and which may improve as their depression is appropriately treated. The

reported incidence rates of depression in this patient group vary widly.

Hopelessness may to some degree be understood as a normal phenomenon in

human life. A person experiences the feelings of hopelessness in different

situation. These feelings are transitory in nature and with the mobilization

of mental resources. Psychosocial support, meritalissue, stress, sexual

assult, suicidal ideation, rumination, depression, economical problem and

dysfunctional attitudes have been associated with the hopelessness (Abramson ,

Metalsky , Alloy ,1989).

Hopelessness has been seen reflect giving up the will to live or lack of

sense of meaning and purpose in life. When people feel hopeless they have

difficulties in concretising their plans and realizing alternative ways of

 12

resolving problems or imagining that anyone could help them find a solution to

their problem and they expect little from others or themselves.

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Theory of Hopelessness:

Abramson and colleagues (2002) recently proposed an integration of the

hopelessness theory of depression with Davidson’s (1994) approach/withdrawal

theory of depression. The hopelessness theory (Abramson, Metalsky, & Alloy,

1989) underscores the importance of cognitive processes in the etiology,

maintenance, and treatment of depression. According to thistheory, some

individuals have a cognitive vulnerability that interacts with stress

toproduce depression. Specifically, the hopelessness theory posits that people

arevulnerable to depression because they tend to generate interpretations of

stressful lifeevents that have negative implications for their future and for

their self-worth. People who generate these negative interpretations develop

hopelessness, which is a proximaland sufficient cause of hopelessness

depression (a theoretically derived subtype ofdepression characterized by

symptoms such as retarded initiation of responses, lack of energy, sad affect,

and apathy (Abramson . 1989). Recent research has providedstrong support for

hopelessness theory and has highlighted the important role thatcognition plays

in the development of depression (Abramson,. 2002).

In contrast to the hopelessness theory, Davidson’s approach withdrawal

theory emphasizes motivational factors in depression. Experimental

psychologists have converged on the conclusion that there are at least two
 14

fundamental motivational systems that are critical in regulating behavior. One

system regulates approach behaviorto attain rewards and goals; it is typically

referred to as the approach system (Davidson1994). The other system regulates

withdrawal and or inhibition of behavior in responseto threat and punishment

and accordingly, is referred to as the withdrawal system. Within this

motivational perspective, depression is most often viewed as a dysregulationof

the approach system (Shankman and Klein 2003).

Davidson and colleagues have investigated the relationship between

approachmotivation and depression by delineating the neural circuitry

implementing theapproach and withdrawal systems. Specifically, Davidson (1994)

contends that approach motivation is implemented in the left prefrontal cortex

whereas the withdrawal system isimplemented in the right prefrontal cortex For

example, the approach system, as measured by ( Carver and White’s (1994)

BIS/BASscale) is associated with increased left frontal cortical activity

during resting baseline(Harmon-Jones & Allen 1997; Sutton & Davidson 1997). In

regard to depression.

Davidson and colleagues have consistently shownthat depressed

individuals exhibit less relative left sided frontal activation than non

depressed individuals. This frontal asymmetry appears to be state-independent

because asymptomatic remitted depressed individuals also exhibit less relative

left-sided frontal activation than never depressed individuals (e.g., Gotlib.

 15

1998; Henriquesand Davidson 1990). Based on these and other findings, Davidson

and colleagues (Davidson,1994 & Gotlib, 1998) have argued that relative less

left frontal

activation represents an impaired approach system and a vulnerability to

depression of the approach system (Shankman & Klein 2003).

Does Davidson’s impaired approach system constitute a vulnerability to

depression that is independent from the cognitive vulnerability factor

featured hopelessness theory? According to Abramson and colleagues (2002), the

answer is ‘‘no.’’ They proposethat cognition may influence the functioning

of the biologically based motivational system described by Davidson.

Specifically, hopelessness may ‘‘shut down’’ the approach systemso that an

individual is no longer motivated to pursue rewards and goals. Hopelessness

isthe expectation that highly desired outcomes will not occur or that highly

aversive outcomes will occur and that one cannot change this situation. It is

the expectation towhich cognitively vulnerable individuals are hypothesized to

be predisposed. Abramson and colleagues argue that as expectancies of

hopelessness increase, goal-directed behaviorwill decrease ( Fowles 1993).

Consistent with this reasoning, many of thesymptoms of the hopelessness

depression (e.g., apathy, lack of energy, and retardedinitiation of responses)

appear to reflect deficits in approach motivation.

 16

According to this integrated framework, when cognitively vulnerable

individual counter a stressful life situation, they tend to generate negative

inferences about theirfuture and self-worth. These inferences lead to

hopelessness about achieving currentand future life goals. As hopelessness

increases, the approach system shuts down. Thisshut-down is reflected by

decreases in goal-directed behavior. Put more simply, theinteraction of

cognitive vulnerability and stress should predict hopelessness, and in

turn,lead to decreases in goal-directed behavior.

The current study tested Abramson and colleagues’ (2002) hypothesis

that cognitively vulnerable individuals are at risk for decreased approach

behavior in the presenceof stress. The study used a 5-week prospective

longitudinal design and tested amediation model of cognitive vulnerability and

goal-directed behavior. Specifically, we hypothesized that cognitive

vulnerability would interact with stress to predicthopelessness, and in turn,

lead to decreases in goal-directed behavior. In addition, wetested the

hypothesis that changes in goal-directed behavior are associated withincreases

in depressive symptoms.
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Sign of Hopelessness

 Feeling depressed

 Trouble in sleeping

 Feeling anxious

 Withdrawing

 Losing interest

 Extreme guilt

 Feeling of failure

 Feeling trapped

 Poor performing

 Feel like burden of others

 Thinking about suicide

 No need to stay alive

Types of Hopelessness

1.Alienation (Attachment)

Alienated individuals believe that they are somehow different.Moreover

they feel as if they have been cut loose no longer deemed worthy of love,care

or support.In turn the alienated tend to close themselves off.

2.Forsakenness (Attachment and Survival)

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The word Forsaken refers to have experience of total abandonment that

leaves individuals feeling alone in their time of greatest need recall job in

the old treatment, crumpled over and covered with sores pleading with a

seemingly indifferent god.

3.Uninspired (Attachment and mastery)

Feeling uninspired can be especially difficult for mambers of

underprivileged minorities for whom opportunities for growth and positive role

models within the group may be either lacking or undervalued.

4.Powerlessness (Mastery)

Individuals of every age need to believe that they can author the story

of their life.When that need is thwarted.When one feels incapable of

navigating one’s way toward desired goals a feeling of powerlessness can set

in

5.Oppression (Mastery and Attachment)

Oppression involves the subjugation of a person or group

6.Limitedness (Mastery and survival)

When the struggle for servivel is combined with a sens of failed mastery

individual feel limited.

7.Doom (survival)

Individuals weighed down by this form of despair presume that their life

is over that their death is imminent.

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8,Captivity(Survival and attachment)

Two forms of hopelessness can result from captivity.The first consists

of physical or emotional captivity enforced by an individual or a

group.Prisoners fall into this category as well as those help captive in a

controlling abusive relationship.

9.Helplessness (Survival and mastery)

Helpless individuals no longer believe that they can live safety in the

world .They exposed and vulnerable.

Hopelessness also mediates the associated between other risk factor and

suicidality such as dysfunctional attitudes, childhood maltreatment, and life

stress. These studies suggest that hopelessness may be a mechanism through

which other risk factors lead to suicidal ideation.

Another variables also link with the hopelessness which may cause the

suicidal ideation or suicide attempters.

Dysfunctional attitudes

Dysfunctional attitudes refers to not performing normally as an organ or

structure of the body.Its having a malfunctioning part or element.

Dysfuntional attitudes are negatively biased views of oneself the world and

the future. Modest level of dysfunctional attitudes are healthy. The level of
 20

the dysfunctional attitudes usually increase beyond the healthy range during

hopelessness episode. The level of dysfunctional attitudes has also been shown

to be higher than normal in patients with self harm behavior.

Example of dysfunctional attitudes include; My value as a person depends

entirely on what others think of me…

Individuals vulnerable to depression have maladaptive schemas, which

remain dormant until triggered by stressful life events Dysfunctional beliefs

reflect the content of these relatively stable schemas. In the past, many

studies were unsuccessful in demonstrating this cognitive vulnerability;

dysfunctional beliefs seemed to covary with depressive symptoms, suggesting

state dependency rather than vulnerability. According to Beck's theory,

schemas serve to organize prior experience, guide the interpretation of new

experiences, and shape expectancies and predictions. Dysfunctional schemas are

thought to serve as vulnerability factors for psychopathology during no

symptomatic periods, when they are usually latent or mildly valent. In the

presence of relevant environmental triggers, they become activated and

hypervalent and contribute to the initiation and maintenance of episodes of

psychiatric disorders.

Early research on these cognitive biases demonstrated that dysfunctional

attitude are more frequently by clinical than non clinical populations

especially in the context of depression. More recently research has suggested

 21

that these maladaptive beliefs may serve as an antecedent vulnerability factor

for the development of psychopathology and may also contribute to the

maintenance and recurrence of psychiatric and behavioral problems over

time(Hankin and Abramson).

Rumination

Another risk factor for depression that has received growing attention

in the literature is a ruminative response style (The tendency for individuals

to recursively mull over the cause consequences and symptoms of their

depressed mood).only one study to date has examined the relationship between

rumination and suicidal ideation.Eshunreported that links between ruminative

responding and suicidal ideation from university student.Given the ruminators

experience an incessant barrage of negative thoughts it is possible that

ruminative responding to negative affect may lead to increased hopelessness

which in turn increases one’s risk of suicidality. Rumination, broadly

defined as enduring, repetitive, self-focused thinking which is afrequent

reaction to depressed mood (Rippere, 1977),Ruminatiom has been frequently

associated with theproximal predictors of suicidality: depression and

hopelessness.

Rumination has been identified as a risk factor for both aggression

(Bushman) and depression (Morrow & Nolen hoeksema). Sadness rumination has
 22

been conceptualized as repetitive thinking that focuse on one’s sadness, and

attempts at understanding one’s affect (Conway 2000).

Literature review

Suicide is responsible for over 31000deaths per year, making it the

ninth leading cause of death in America (Anderson,Kochanek, & Murphy, 1997).

However,given that suicide accounts for approximately1.4%of the total deaths

in America (Anderson., 1997), it is an infrequent event. The relatively low

incidence complicates identification of those individuals who will eventually

kill themselves. Clinicians are continually confronted with the problem of

estimating whether psychiatric patient is at risk for committing suicide. Such

a decision is crucial forpatient management and, especially,

longtermmonitoring. However, given the infrequency of suicide, the

identification of clinical predictors of eventual suicide has-been

problematic. Large samples, a prospective study design, and long-term follow-

up are required to detect empirically validated risk factors.

In adult populations, self-oriented perfectionism and, even more so,

socially prescribed perfectionism have been found to be correlated with

suicide intent and threat.14 Socially prescribed perfectionism has also been
 23

shown to be elevated in adult patients with diagnoses associated with suicide,

such as depression.14 In addition, socially prescribed perfectionism

contributed unique variance to suicide threat and ideation above and beyond

that accounted for by depression and hopelessness. In another study,11 66

adolescent psychiatric inpatients (33 boys and 33 girls) had higher levels of

self-oriented than socially prescribed perfectionism. Both self-and socially

prescribed perfectionism were positively correlated with hopelessness and and

suicidal ideation . However,only the relation between socially prescribed

perfectionism and suicidal ideation attained significance. Moreover, only

socially prescribed perfectionism contributed unique variance to suicidal

ideation when the effects of age, gender, self-oriented perfectionism, and

hopelessnesswere controlled.

The literature on adolescent suicide is replete with references to

perfectionism (the setting

and maintaining of unrealistically high standards and expectations, critical

evaluations of performance, etc.) as a cognitive or personality style that is

predictive of suicide attempts (Blatt, 1995; Blatt & Zuroff, 1992). Shaffer

(1974), for example, noted that a sample of adolescents who had committed

suicide had shown high levels of perfectionism and self criticalness and

Stephens (1987) described a group of highly suicidal girls as having

backgrounds wherenot only was perfection demanded of them by significant

 24

others, but where these girls believed they needed to attain their own highly

perfectionistic standards. Goldsmith, Fyer, & Frances (1990) and Maltsberger

(1986) have stated that perfectionistic behavior may significantly increase

the probability of suicidal behavior, especially during adolescence. Likewise,

Ranieri. (1987) suggested that two dimensions of dysfunctional thinking were

related to suicidal ideation. Both perfectionistic attitudes and sensitivity

to criticism accounted for independent variance in suicide ideation ( Marks &

Haller, 1977; Woods & Muller, 1988). Finally, one group whose members are seen

as particularly prone to suicide due to extreme perfectionism is

intellectually gifted youth (Delisle, 1990). Finally, Baumeister(1990)

suggested that failure to attain unrealistic standards derived either from the

self or from others is a major factor in initiating suicide attempts.

There is many researches about suicide and suicide ideation.The vast

majority of suicide related research has focused on adults and adolescents

whereas research on children has been quite limited. Most researches has

focused on the relation between hopelessness and suicide related outcomes.

suicide ideation and attempts are preceded by commom stressful life event.

Depression and suicidal ideation and attempts are result of a person cognitive

distortionthrough which an individual systematically misconstrues the

environment in a negative way.These cognitive distortion are not observable it

 25

is possible to assess their presence by measuring the content and frequency of

an individual negative automatic thoughts.

Several factors for suicidal thinking have emerged in the literature

among them.depressogenic thinking. More specifically a negative inferential

style in response to n egative life events has been linked to increased

suicidality in university student as well as in psychiatric inpatients

(Abramson 1998 & Ranieri 1987).Similarly Beck, Steer and Brown (1993) reported

that suicidal psychiatric outpatients exhibited Dysfunctional attitudes than

those with out suicidal ideation.These studies all suggest that depressogenic

thinking in the form of negative inferential style and dysfunctional attitudes

is related to and may initiate self injurious thoughts.

Hopelessness has been found to correlate with suicide intent and suicide

(Minkoff, Bergman,Beck, & Beck, 1973). To date, most studies investigating the

relationship of these two variables have been based on the Beck Hopelessness

(Beck, Wcissman, Lester, &Trexler, 1974), Depression (Beck, Ward, Mendclson,

Mock, & Erbaugh,1961), and Suicide Intent (Beck, Resnik, & Letticri, 1974)

scales. Results have indicated that hopelessness scores are a better indicator

of suicide intent among previous parasuicides than are depression scores

(Minkoff et al., 1973). Theseresults have then been interpreted as indicating

that hopeless cognitions play an important role in the etiology of suicidal

 26

behavior. However, none of these studies has explored the relationship between

report of hopelessness, report of suicidalbehavior, and general tendency to

answer questions in a socially desirable fashion.

The most well established organizing framework for research on this

topic is cognitive theory (Beck, 1967 Clarkel al 1999).According to cognitive

theory dysfunctional attitudes are embedded in a stress framework that aims to

explain the development maintenance and recurrence of psychopathology

particularly anxiety disorders and depression. The underlying cognitive

schemas that give rise to dysfunctional attitudes are hypothesized to remain

latent until an individual experience a stressor that activates the schemas.

When activated by stress the dysfunctional attitudes become salient to the

individual and increase risk for affective and behavioral disturbance.

Supporting this diathesis perspective several but not all. Longitudinal

studies have demonstrated an interactive effect between dysfunctional

attitudes and major stressful life events in predicting emotional pathology.

one issue not frequently discussed in this literature concerns the fact that

the vast majority of stressors that individuals respond to on a daily basis

are not major stressful life event but events in the minor to moderate

severity range (daily hassles, minor life events). We are aware only one study

that has gone beyond examining major stressful life events to focus on how

dysfunctional attitudes are influenced by more minor stressors occurring on a

 27

daily basis.some prior research has challenged the view that dysfunctional

attitudes are conceptually independent from broader vulnerabilities for

internalizing distress for example irrational thinking low self esteem. At

least one study has shown that dysfunctional attitudes are related to

depression through their association with hopelessness. Dysfunctional

attitudes are important factor that can contribute the suicidal ideation.some

investigators have recently broadened the scope of research on vulnerability

factors interact with biological processes and social environmental exposures

to shape risk for effective disorder . Several multi factorial models of

psychopathology have been proposed (e.g Gibb, 2013 kendler 2008;slavich &

Irwin2014;Slavich, 2010).The most rapidly growing body of research in this

context focuses on genetic factors interact with environmental exposures to

shape risk foe effective disorder

Several metanalytic reviews have demonstrated that when prior hypotheses

and good measurement techniques are employed prospective risk for

depression.Individual who depressed have depressed have dysfunctional

attitudes which when activated by stressful life event cause depression. The

number of studies have shown that dysfunctional attitudes are not elevated

when depression individuals are asymptomatic.in the only prospective study of

dysfunctional attitudes and depression in adults.

 28

Lewinsohn,Steinmetz,Larson and Franklin (1981) examined whether

cognitive vulnerability is present before an episode of depression.They found

that people who later developed depression did not report more dysfunctional

cognitions when asymptomatic than persons did not report more dysfunctional

cognitions when asymptomatic than person who did not become

depressed.Similarly in comparison of previously depressed and never depressed

individual investigators typically have failed to find that previously

depressed individuals exceed never depressed individuals in level of

dysfunctional attitudes or negative attributions.

It is estimated that between 20% and 30% of cancer patients will

experience clinically significant depressive symptoms at any one time.

However, physicians and nursing staff often underrecognize depression in

oncology patients. A common mistake is to assume that depression represents

nothing more than a natural and understandable reaction to an incurable

illness (Scherer-Rath, 2001).

Social support has been defined in the literature as the assistance and

protection given to others, especially to individuals. Support and assistance

from family members is helpful in aiding the patient cope with stress

resulting from the disease and treatment. Scientists have for many years

recognized a positive relationship between social support and health (Tan and

Karabulutlu, 2005). Social support is well documented as one of the most

 29

popular and preferred modes of coping with hopelessness; indeed, this is also

indicated in the general population (Scherer- Rath, 2001). There is apparent

debate as to the relative importance of social support, including

instrumental, emotional, and informational support, versus social networks,

the ties through which support is provided to cancer survival. Social support,

spiritual support, and disease-related factors like metastasis, performance

status, and duration of cancer diagnosis need to be considered in nursing

intervention in order to maintain a fighting spirit and to overcome feelings

of hopelessness and depression in cancer patients (Pessin., 2002). Determining

the perceived levels of social support from the family and the levels of

hopelessness and depression of individuals with cancer is important in

planning the care for these patients, in ensuring the contribution of

families, and in increasing life quality, thereby increasing the quality of

care. The purpose of the current study was to define the relationship between

different demographic variables and hopelessness, depression, and social

support. Suicidal ideation and attempts are preceded by common, stressful life

events (Spirito, Overholser & Stark, 1989). The ways children perceive and

evaluate such events, and their resulting thoughts, may be an important

consideration for identifying those who are potentially suicidal. Beck,

Kovacs, and Weissman (1975) postulated that depression and suicidal ideation

and attempts are results of a person’s “cognitive distortions,” through

 30

which an individual systematically misconstrues the environment in a negative

way. Although these cognitive distortions are not directly observable, it is

possible to assess their presence by measuring the content and frequency of an

individual’s“negative automatic thoughts.” Negative automatic thoughts are

private, spontaneous, intrusive, negative statements believed to represent an

individual’s underlying belief system. Indeed, negative automatic thoughts

occur significantly more frequently in depressedthan in nondepressed adults

and children (Hollon& Kendall, 1980; Kazdin, 1990).Despite the fact that

negative automatic thoughts have been linked to depressed mood and the

modification of negative automatic thoughts has featured prominentlyin

treatments for suicidal children and adolescents (e.g., Brent&Poling, 1997),

the relation between the frequency of negative automatic thoughts and

suicidalideation and attempts has not been examined empirically.

Following the logic of Beck and colleagues (1975) that suicidal ideation

and attempts are the result of cognitive distortions, children who are

currently suicidalwouldbe expected to experience an increased frequency of

negative automatic thoughts. An increasedfrequency of negative automatic

thoughts may make the experience of stressors less tolerable for some

children, and these children may resort to suicidal ideation.

A number of studies have shown that dysfunctional cognitions are not

elevated when depression-prone individuals are asymptomatic. In the only

 31

prospective study of dysfunctional cognitions and depression in adults ‚

Lewinsohn‚ Steinmetz‚ Larson‚ and Franklin (1981) examined whether cognitive

vulnerability is pre sent before an episode of depression. They found that

people who late r developed depression did not report more dysfunctional

cognitions when asymptomatic than persons who did not become depressed.

Similarly‚ in comparisons of previously-depressed and never-depressed

individuals ‚investigators typically have failed to find that previously

depressed individuals exceed never-depressed individuals in levels of

dysfunctional attitude s or negative attributions‚ despite the fact that

previously depressed individuals are known to be at substantially elevated

risk for future depression (Blackburn‚ Roxborough‚ Muir‚ Glabus‚ & Blackwood‚

1990; Blackburn & Smyth‚ 1985; Dohr‚ Ruch‚ &Bernste in‚ 1989; Eave s & Rush‚

1984; Hamilton & Abramson‚ 1983; Hollon‚ Kendall ‚ &

Lumry‚ 1986; Persons &Rao‚ 1985; Reda‚ Carpiniello‚ Secchiaroli ‚ & Blanco‚

1985;

Silverman‚ Silverman‚ &Eardle y‚ 1984; Simons‚ Garfield‚ & Murphy‚ 1984) .

Definition:

Suicide:

The act of killing yourself because you do not want to continue living.

Hopelessness:
 32

Hopelessness is a subjective state in which an individual see limited or

no alternatives or personal choices available and is unable to mobilize energy

on own behalf.

Dysfunctional attitude:

It refers to the Abnormal or impaired functioning of a bodily

system or organ.

Rumination:

It refers to the tendency to repetitively think about the causes,

situational factor, and consequences of one’s negative emotional experience.

Objectives;

1. To study the effect of Dysfunctional attitudes, Rumination and

Hopelessness among suicide patient.

2. To find the relationship Dysfunctional attitudes, Rumination and

Hopelessness among suicide patient.

Hypothesis;

1. Dysfunctional attitude will significant effect on hopelessness.

2. Rumination will impact on hopelessness.

Chapter 2
 33

Method

Participants

Approximately 70 above participants would be used in this study. The

participants selected from the Nishter hospital Multan (ages ranging

from 18 to 30).

Instrument

 Beck Hopelessness scale (BHS)

 Dysfunctional attitudes scale (DAS)

 Rumination response style (RRS)

This study carried out with the use of questionnaire to gather data.

The questionnaire was structured.

Beck hopelessness scale (BHS):

Beck was developed the hopelessness scale in 1974 to study of negative

expectations and their relationship to psychopathology. Nine items were

selected from a test concerning attitudes about future and 11 items were drawn

from a series of pessimistic statements made by psychiatric patients.

The BHS of 20 items which rating scale constructed in a forced choice

(true & false).

 34

Scoring (0-3) no hopelessness, (4-8) mild hopelessness, (9-14) moderate

hopelessness, (15-20) severe hopelessness.

Dysfunctional attitudes scale. (DAS)

This scale developed by the Weissman and Beck 1978. The dysfunctional

attitudes scale is a self- report scale designed to measure the presence and

intensity of dysfunctional attitudes. The DSA consist of 40 items and each

item consist of a statement and a 7-point Likert scale (7=totally agree;

1=totally disagree). Ten items are reversely coded (2, 6, 12, 17, 24, 29, 30,

35, 37 and 40). The total score is the sum of the 40 items with a range of 40-

280.

Rumination response style(RRS)

This scale was developed by Susan Nolen Hoeksma. This scale consist of

22 items and each item consist of a statement and a 4 point Likert scale

(1=almost never; 4=almost always).

Procedure

The participants of the study were personally. Before administering the

Beck hopelessness scale, Dysfunctional attitude scale and rumination response

style scale required personal information was obtained through the demographic

sheet and the confidentiality of their information was ensured. They were
 35

briefed regarding the nature and objectives of the study. Purposive sampling

technique was been used and interviewing method for the administration of the

scales. First the demographic form were administered to a portion of the

sample individually then the interviews held. Afterwards the two scales were

administered to the sample individually.

All of the participants volunteered; none were paid or compensated for

their participation. Data were collected in individual sessions, and

instructions were presented in written form. The between-participants order of

the presentation of the questionnaires was randomized.

Chapter 3

Result

This section concentrates on measurable examination of exploration information

by utilizing SPSS 21.0. Importance level 0.05 was utilized for all

examination. Descriptive measurements was utilized to measure mean, standard

deviation, and Cranach’s Alpha. Pearson coefficient relationship was

ascertained to analyze the effect of dysfunctional attitude, rumination and

hopelessness among suicide patient. Linear regression was used to examinations

 36

the directing impact of dysfunctional attitude, rumination on hopelessness

among suicidal.

3.1. Preliminary Analysis

In this study, researcher collected three standardized scales: beck

hopelessness scale (BHS), Dysfunctional attitude scale (DAS), Rumination

response style (RRS).Cronbach’s alpha of scales administered in present

research is given in table 3.1

Sr. no Scales Cranach’s Alpha Item No

1 BHS .755 20

2 DAS .806 40

3 RRS .863 22

Table 3.2

Descriptive Statistics for the study variables

 37

Variable M SD Minimum Maximum

1 BHS .5113 .20015 .05 .85

2 DAS 4.45 3.4692 1.60 4.45

3 RRS 3.59 2.4937 1.18 3.59

Table 3.2 showing descriptive statistics of study variable. Beck hopelessness

scale, dysfunctional attitude scale and Rumination response style has a

maximum value of 4.45

 38

Co-relational Coefficient of Variables

To find out the relationship between variables by Pearson

correlation coefficient in results shows in the table 3.3

Table 3.3

Correlation Coefficient Matrix of dysfunctional attitude, hopelessness, and

rumination.

Correlations

age Gender educati m.status Occupatio s.statu meanbhs meandas meanrrs

on n s

Age 1 -.175 -.230* .623** -.192 -.045 -.050 .057 -.123

Gender 1 .234* -.089 .193 -.396** .055 .082 .024

1 -.514** -.168 -.054 .023 .163 .066

Education

1 -.161 -.002 -.089 -.224* -.215

m.status

1 .159 -.138 .056 -.042

Occupatio

s.status 1 -.092 -.250* -.172

 39

Bhs 1 -.105 .058

Das 1 -.120

Rrs

*. Correlation is significant at the 0.05 level (2-tailed).

**. Correlation is significant at the 0.01 level (2-tailed).

Table 3.3 presents the relationship among hopelessness, dysfunctional attitude

and rumination. Hopelessness was not correlated with dysfunctional attitude

(r = -.120), hopelessness was not correlated with rumination.

There was negative correlated in marital status and dysfunctional

attitude(r=- .224,). Also there was negative correlated in social status and

dysfunctional attitude and also there was correlation in demoghrapfic

variable.

Result findings indicates that there is positive significant correlation

between variables and also less correlation between marital status and

dysfunctional attitude and there is no correlation between scale.

 40

Table 3.4

Linear regression analysis showing direct effect of dysfunctional attitude on

hopelessness among suicidal patient.

Model B SE ß T P

.630 .129 4.893 .000

Constant

-1.738 .201 -.105 -.937 .352

DAS

Note. R²= .011, Adjusted R² = -.002, F (.877), P<0.05

Table 3.4 indicates the regression analysis for showing the effect of

dysfunctional attitude on hopelessness . The R2value is .011 that indicates

that internalized stigma predicts the effects on hopelessness 1.1

 41

Table 3.5

Linear regression analysis showing direct effect of rumination on hopelessness

of among suicidal patient.

Model B SE ß T P

.448 .124 3.603 .001

Constant

.025 .049 .059 .515 .608

RRS

Note. R²= .003, Adjusted R² = -.009, F (.266), P<0.05

Table 3.5 indicates the regression analysis for showing the effect of

rumination on hopelessness. Findings revealed that internalized stigma

regressed hopelessness. The R2value is .003 that indicates that internalized

stigma predicts the effects on hopelessness 0.3%.

 42

Chapter 4

Discussion

The main objective of present research is to investigate the effect of

Dysfunctional attitude, rumination and Hopelessness among suicide patient.

Anxiety, depression and stress are commonly present in such patients. So the

aim was to explore the connection and association of this hopelessness,

dysfunctoional attitude, rumination and hopelessness among suicide patient.

Researchers suggest that female, adolescent and later adulthood should

affect by the hopelessness and commite to suicide. Patients with different

cultural backgrounds and different demographics will have different values,

norms and believe patterns and this will influence the patients who commite

suicide.

Analysis was conducted on eighty suicidal patient. Participants were

selected from Nishter Hospital Multan in this research (ages ranging from 19

to 39). The method used for sampling was purposive sampling. Patients had

various demographical variables.

The finding was collected by statistical applications of the

administered scales presents a significant association among the Bhs, Das and

Rrs scale.
 43

It was hypothesized that dysfunctional attitude will significant effect on

hopelessness among suicidal patient.

According to the table 3.4 the hypothesis is rejected because there is no

significant correlation between dysfunctional attitude and hopelessness.

One study suggest that Hopelessness did not significantly change over the

course of treatment for the patients who later committed suicide. There was no

correlation between dysfunctional attitude between hopelessness.

Second hypothesized rumination will impact hopelessness.

According to the table 3.5 hypothesis was rejected because there is no

correlation rumination and hopelessness.

But in this present study there is correlation between demographic variable.

 44

Conclusion

The aim of this research was to determine the effect of hopelessness,

dysfunctional attitude, rumination and hopelessness among suicide patient. The

research shows that there is no significant correlation between dysfunctional

attitude, rumination and hopelessness but in this study there is correlation

present in demographic variables and also marital, social status with

dysfunctional attitude.

This study shows that dysfunctional attitude and rumination directly

effect on hopelessness among suicidal patient.

 45

Limitations

1. The sample was restricted to the city of Multan.

2. Participant were not respond sincerely.

3. Most of sample consisted of literate persons.

4. The research would not be consider as generalized because the sample

size is too short

 46

Suggestion

1. Research should be conducted on vast area of population.

2. Sample should be large and homogeneous in nature.

3. Information should also be gathered through interview so that the

researcher could get more reliable data for analysis.

47
 48

References

Abramson, L. Y., Metalsky, G. I., & Alloy, L. B. (1989). Hopelessness

depression: A theory-based subtype of depression. Psychological Review,

96, 358–372.

Abramson, L. Y., Alloy, A. B., Hogan, M. E., Whitehouse, W. G., Cornette, M.,

Akhavan, S., et al. (1998). Suicidality and cognitive vulnerability to

depression among college students: A prospective study. Journal of

Adolescence,

Alcohol, Drug Abuse, and Mental Health Administration. (1989). Report of the

secretary's task force on youth suicide (DHHS Publication No. ADM 89-

1621). Washington, DC: U.S. Government Printing Office.

Abramson LY, Metalsky GI, Alloy LB (1989). Hopelessness depression: a

theorybased of depression.

Avci IA, Okanli A, Karabulutlu E, Bilgili N (2009). Women’s marital

adjustment and hopelessness levels after mastectomy..

Anderson, R. N., Kochanek, K. D., & Murphy, S. L. (1997, June 12). Report

ofFinal Mortality Statistics, 1995.

Abramson, L. Y., Alloy, L. B., Hankin, B. L., Haeffel, G. J., MacCoon, D. G.,

& Gibb, B. E. (2002).

 49

Beck, A. T., Steer, R. A., & Brown, G. (1993). Dysfunctional attitudes and

suicidal ideationin psychiatric outpatients. Suicide and LifeThreatening

BehaviorBerman, A. L., &Jobes, D. A. (1991).Adolescent suicide:

Assessment and intervention. Washington, DC: American Psychological

Association.

Beck, A.T., Steer, R.A., Kovacs, M. & Garrison, B. (1985). Hopelessness and

eventualsuicide: A 10-year prospective study of patients hospitalised

with suicidal ideation.American Journal of Psychiatry,.

Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy

of depression. New York: Guilford press.

Beck, A. T. (1983). Cognitive therapy of depression: New perspectives. In P.

J. Clayton & J. E. Barrett (Eds.), Treatment of depression: Old

controversies and new approaches (pp.265–290). New York: Raven Press.

Blatt, S. &Zuroff, D.(1992). Interpersonal relatedness and selfdefinition:Two

prototypes for depression. Clinical Psychology Review, 12, 527-562.

Beck, A. T., Weissman, A, Lester, D., &Trexler, M. (1974). The measurement of

pessimism: The Hopelessness Scale. Journal of Consulting and Clinical

PsychologiocalConway, M., Csank, P.A.R., Holm, S.L. & Blake, C.K.

(2000). On assessing individualdifferences in rumination on sadness.

Journal of Personality Assessment,

 50

Dept. of Health (2002). National Suicide Prevention Strategy for England.

HMSO: London.Davidson, R. J., Pizzagalli, D., Nitschke, J. B. (2002).

The representation and regulation of emotion in depression. Perspectives

from affective neuroscience. In I. H. Gotlib& C. L. Hammen (Eds.),

Handbook of depression. New York: Guilford.

Derogatis, L.R. (1977).The SCL-90 Manual I: Scoring, administration and

procedures for \SCL-90. Baltimore: Clinical Psychometric Research.

Eshun, S. (2000). Role of gender and rumination in suicide ideation: A

comparison of

college samples from Ghana and the U.S. Cross Cultural Research, 34,

250-263.

Delisle, J. R. (1990). The gifted adolescent at risk: Strategies

andresources for suicide prevention among gifted youth. Journalof

Education of the Gifted, 13, 212-228.

Grumann MM, Spiegel D (2003). Living in the face of death: interviews

with 12 terminally ill women on home hospice care. Palliat Support

Care, 1, 23-32. Jones JM, Huggins MA, Rydall AC, Rodin GM (2003).

Symptomatic distress, hopelessness, and the desire for hastened

death in hospitalized cancer patients. J Psychosom Res, 55, 411-

8.
 51

Goldsmith, S. J., Fyer, M., & Frances, A. (1990). Personality and

suicide. In S. J. Blumenthal & D. J. Kupfer (Eds.),Suicide over

the life cycle (pp. 155-176). Washington, DC: American Psychiatric

Press.

Gotlib, I. H., Ranganath, C., & Rosenfeld, J. P. (1998). Frontal EEG

alpha asymmetry, depression, and cognitive functioning. Cognition

and Emotion, 12, 449–478.

Holinger, R, & Offer, D. (1981). Perspectives of suicide in adolescence.

In R. Simmons (Ed.), Research in community andmental health (Vol.

2, pp. 139-157).

Greenwich, CT. JAI Press. Woznlca, J. G., & Shapiro, J. (1990). An

analysis of adolescentsuicide attempts: The expendable child.

Journal of PediatricPsychology, 15, 789-796.

H. Gotlib& C. L. Hammen (Eds.), Handbook of depression. New York:

Guilford.

Hankin, B. L., & Abramson, L. Y. (2001). Development of gender

differences in depression: An elaborated cognitive

vulnerabilitytransactional stress theory. Psychological Bulletin,

127,773–796.

Harmon-Jones, E., & Allen, J. J. B. (1997). Behavioral activation

sensitivity and resting frontal EEG asymmetry: Covariation of

 52

putative indicators related to risk for mood disorders. Journal of

Abnormal Psychology, 106, 159–163.

Joiner, T.E., Pettit, J.W., Walker, R.L., Voelz, Z.R., Cruz, J., Rudd,

M.D. & Lester, D. (2002).

Korean Statistical Information System. Change in populations, Statistics

2004.

Litinsky, A.M. & Haslam, N. (1998). Dichotomous thinking as a sign of

suicide risk on the TAT. Journal of Personality Assessment, 71,

368-378.

Pollock, L. & Williams, J.M.G. (2004). Problem solving in suicide

attempters. Psychological Medicine, 34, 163-167.

Maltsberger, J. T, (1986). Suicide risk New York: New York Universities

Press

Marks, P. A., & Haller, D. L. (1977). Now I lay me down for keeps: A

study of adolescent suicide attempts. Journal of Clinical

Psychology,Minkoff, K., Bergman, E., Beck, A. T., & Beck, R.

Hopelessness, depression, and attempted suicide. American Journal

of Psychiatry, 1973,130, 455-459.

Nolen-Hoeksema, S. (1987). Sex differences in unipolar depression:

Evidence and theory.Psychological Bulletin, 101, 259-282.

 53

O'Connor, R.C., O'Connor, D.B, O'Connor, S.M., Smallwood, J & Miles, J.

(2004).

Perceived burdensomeness and suicidality: Two studies on the suicide

notes of thoseattempting and those completing suicide. Journal of

Social and Clinical Psychology, 21, 531-545.

Okamura M, Yamawaki S, Akechi T, et al (2005). Psychiatric disorders

following first breast cancer recurrence: prevalence, associated

factors and relationship to quality of life. Jpn J ClinOncol, 35,

302-9. Cognitive vulnerability-stress models of depression in a

self-regulatory, psychobiological context.

Shaw, K. R., Sheehan, K. H., & Fernandez, R. C. (1987). Suicide in

children and adolescents. Advances in Pediatrics, 34, 314-334.

Shaffer, D., Garland, A., Gould, M., Fisher, P., &Trautman, P. (1988).

Preventing teenage suicide: A critical review. Journal of the

American Academy of Child Adolescent Psychiatry, 27,657-687.

Shankman, S. A., & Klein, D. N. (2003). The relation between depression

and anxiety: An evaluation of tripartite and approach-withdrawal

and valence-arousal models. Clinical Psychology Review, 23,605–

637.

Williams, J.M.G. (1996). Depression and the specificity of

autobiographical memory. InD.C. Rubin (Ed.),Remembering Our Past

 54

– Studies in Autobiographical Memory.Cambridge: Cambridge

University Pres Weissman, A. N. (1979). The Dysfunctional Attitude

Scale: A validation study. Dissertation Abstracts International,

40, 1389B-1390B. (University Microfilms No. 79-19, 533).