Investigating the Perceived Impact of Psychosis on Suicidal Thoughts and Behaviors

Abstract

There is evidence showing a link between experiencing psychosis and suicidal thoughts and behaviors. However, individual accounts of the impact of psychosis on suicidal experiences have not been examined in detail. This study aimed to investigate the perceived impact of psychosis on suicidal thoughts and behaviors from the perspectives of individuals with these experiences. Semi-structured interviews with 20 people with non-affective psychosis and lifetime experiences of suicidal thoughts and/or behaviors were conducted. Data were analyzed using inductive Thematic Analysis. Based on participants’ experiences of psychosis and suicidal thoughts and behaviors, 3 themes were identified, including (1) Psychosis experiences are immensely distressing, (2) Changes in behaviors and appraisals of self, and (3) Suicidality as a means of escaping distress. A practical heuristic was proposed, describing a vicious cycle between psychological distress and changes in behaviors and self-appraisals, whereby suicidality was perceived as the only way to escape immense psychological pain. Hallucinations and delusions were central to the development of suicidal experiences. However, certain types of delusions, such as grandiose delusions, were sometimes found to reduce the intensity of suicidal experiences and associated psychological distress. It is necessary to examine the impact of psychosis on individuals, in order to assess the possibility of suicide-related experiences, as certain aspects of psychosis can have an amplifying effect, whereas others can have a weakening effect on those experiences. Minimizing the immense psychological pain experienced by some people with psychosis and the inter-related suicidal thoughts and behaviors is of paramount importance for clinical practice.

Introduction

A large body of literature has identified strong associations between experiencing severe mental health problems, such as schizophrenia, and suicidal thoughts, behaviors, and suicide deaths.^1–3 Between 2006 and 2016, there were 17,150 suicide fatalities in the UK general population, 2,818 of those were by people with schizophrenia.⁴ Experiences of suicidal thoughts and behaviors in people with schizophrenia are even more frequent. Suicidal ideation rates of around 50% and suicide attempt rates between 20% and 40% have been reported.^5,6 A series of studies have identified demographic factors for people with schizophrenia, which contribute to suicidal thoughts, acts, and deaths, including age, unemployment, and poverty.^1,7,8 Additionally, psychological factors, including depression, anxiety, hopelessness, and distress have been associated with increased severity of suicidal experiences.^9–11 Substantial evidence suggests that psychosis symptoms, such as delusions and hallucinations, also strongly predict suicidal thoughts and behaviors.^1,10,12,13 For example, a literature review of 51 studies reported positive associations between experiencing hallucinations and increased rates of suicide deaths.¹ Conversely, auditory hallucinations have also been reported to reduce the risk of death by suicide.⁹ The reasons for the difference in evidence regarding the impact of specific aspects of psychosis and increased or decreased levels of suicidal thoughts and behaviors are unclear.

A limitation in the current knowledge base is that, although there is cumulative research evidencing a link between psychosis and suicidal experiences, there is a paucity of qualitative enquiry into individual perceptions of the severity and impact of psychosis on suicidal experiences. It is plausible that individual reports of such experiences may differ between qualitative (eg, using interviews) and quantitative (eg, using questionnaires) methodological designs, and understanding individuals’ lived experience is an important lens that is currently absent from the literature. Therefore, the aim of this study was to investigate the impact of psychosis symptoms on suicidal thoughts and behaviors, from the perspectives of people with these experiences.

Methods

Study Design

This was an inductive qualitative study using semi-structured, individual face-to-face interviews.

Procedure

Participant Recruitment

A self-selected sample of participants was recruited from 4 UK National Health Service (NHS) mental health trusts and self-help groups in the North West of England between May and December 2017. Individuals were aged 18 or older, were English speaking, had the capacity to provide informed consent, had a current diagnosis of non-affective psychosis, and had experienced suicidal thoughts and/or behaviors in their lifetime. Participants’ diagnosis was confirmed by a member of their mental health team (eg, care coordinator).

Data Collection

The study was conducted after obtaining ethical approval from an NHS Research Ethics Committee (North West – Greater Manchester Central, reference: 17/NW/0211) and in accordance with the World Medical Association’s Declaration of Helsinki regarding the ethics of research involving human participants.¹⁴ Data collection commenced after obtaining participants’ informed consent. The first author conducted all interviews which took place at participants’ homes, university, or mental health service premises, depending on individuals’ preferences. The topic guide comprised open-ended questions about participants’ experiences of psychosis and suicidal thoughts and behaviors (see Appendix 1 for the topic guide). It was developed with input from individuals with suicidal experiences.

Prior to each interview, participants were asked to provide details of their age, gender, diagnosis, ethnicity, occupation, living arrangements, and relationship status. Given the sensitive nature of the topic, changes in mood as a result of participating were monitored using a visual analog scale, which was completed before and after each interview.¹⁵ In addition, a positive mood-inducing task¹⁶ was completed at the end of the interview, which aimed to minimize potential distress or low mood as a result of the interview. A risk protocol, developed with input from service users with suicidal experiences, was followed to ensure that potential distress was handled comprehensively and sensitively.

Data Analysis

All interviews were audio-recorded and transcribed verbatim, and identifiable information was removed. Data were managed using a qualitative software package¹⁷ and analyzed using Thematic Analysis.18 An inductive approach, identifying codes and themes at both semantic and latent levels across the transcripts was adopted.^18,19 Data were analyzed following a constant comparative method, whereby data collection and coding were conducted iteratively.²⁰ A coding framework was developed, based on data from the initial interviews, and updated throughout the data collection period. The framework helped structure the data by reducing it to a set of codes in order to address the research aim.²¹ Data were collected until no new relevant codes were identified through analysis, suggesting a sufficiency of data.²²

Three steps were undertaken to ensure trustworthiness of the analysis. First, members of the research team independently coded a subset of the interview transcripts and participated in discussions about the interpretation of codes.²³ During these discussions, potential disagreements between members were resolved. Second, all members of the research team discussed the grouping of the codes into unique themes, including codes that were different, to represent the diversity of views and experiences. Third, a checklist of 15 strategies for conducting reliable qualitative analysis was used.¹⁸ The research team members had expertise in psychosis, suicide, and qualitative methodology.

Results

Participant Characteristics

Twenty participants took part (see table 1 for characteristics). Four reported experiencing suicidal ideation at the time of the interviews. For the rest of the participants, suicide-related experiences (ie, suicidal thoughts, suicidal urges, suicide attempts) were confined to the past.

Table 1.

Participant Characteristics (N = 20)

Characteristic	Range	Mean (SD), Median or % (n)
Age	23–75	48 (15.5), 48
Gender	–	50% (10) female
Ethnicity	–
White British		80% (16)
Black British		5% (1)
Mixed race		15% (3)
Living arrangements	–
Alone		25% (5)
With family/partner		25% (5)
In supported accommodation		50% (10)
Relationship status	–
Single		80% (16)
In a relationship		10% (2)
Divorced/separated		15% (3)
Employment status	–
Self-employed		5% (1)
Unemployed		55% (11)
Retired		20% (4)
Volunteer		15% (3)
Student		5% (1)
Age of the first contact with mental health services*	14–35	27 (6.2), 28
Current diagnosis	–
Schizophrenia		25% (5)
Paranoid schizophrenia		40% (8)
Chronic schizophrenia		5% (1)
Treatment-resistant schizophrenia		5% (1)
Schizoaffective disorder		10% (2)
Psychotic disorder		5% (1)
Acute psychosis		5% (1)
Unspecified non-organic psychosis		5% (1)

Note: *Data were unavailable for one participant.

Qualitative Findings

Based on participants’ experiences of psychosis and suicidality, 3 themes were identified: (1) Psychosis experiences are immensely distressing, (2) Changes in behaviors and appraisals of self, and (3) Suicidality as a means of escaping distress. Each theme is described and supported with interview quotes. In relation to these findings, we propose a practical heuristic that can enable professionals and researchers to understand the impact of, and relationships between, psychosis and suicidal thoughts and behaviors (figure 1). This heuristic encompasses 2 elements, namely, immense distress in relation to psychosis experiences and changes in behaviors and appraisals of self. Together, these 2 elements form a vicious cycle, whereby suicide is perceived as the only way to escape distress. Therefore, the third element of the heuristic includes suicide as a means of escaping the immense psychological distress.

Fig. 1.

A proposed practical heuristic of the perceived impact of psychosis on suicidal thoughts and behaviors.

Theme 1: Psychosis Experiences are Immensely Distressing

Experiencing severe, long-lasting psychosis symptoms was associated with immense psychological distress, which caused people to think about suicide: “I’ve got these things in my arm that make crawling noises, crawling sensations and they can talk to me as well, and they can make me feel suicidal.” (040, woman). In particular, participants were experiencing paranoid delusions, and auditory, tactile or visual hallucinations, which were exceptionally frightening: “…when I saw them creepy creatures coming to my windows and stuff, then I did [felt suicidal]. I was like that every day and […] I wanted to die.” (021, woman). Understandably, these psychosis experiences put participants in a state of fear, confusion, and inability to make sense of what was happening at the time: “Horrible, horrendous, like really upset, frightened, why this was happening to me, why these voices were shouting this at me – it was awful.” (021, woman).

Some participants equated hearing voices to a constant battle with themselves to not attempt suicide: “I was constantly battling with myself not to do it [suicide]. […] it was like having the Devil and the Angel on my shoulders and one was saying, ‘Don’t do it’ and one was saying, ‘Do it.’” (025, woman). These experiences engulfed participants’ lives and were perceived to have deleterious consequences, not only on their own wellbeing, but on their significant others’ wellbeing, too: “I ended up in an extremely serious situation and really upset my dad, and my dad had to learn how to deal with this, my brother had to learn how to deal with this.” (017, man). People explained that they often became overwhelmed by these intense psychosis experiences which had a major impact on them emotionally: “…it’s like an overwhelming feeling of feeling really, really, really, really desperately, desperately, desperately unhappy… it really is.” (017, man).

Conversely, certain psychosis symptoms, such as grandiose delusions were sometimes perceived to have a weakening effect on suicidal experiences: “No, I wasn’t [feeling suicidal], because it was the idea that I was related to the Queen […] something fantastic was going to happen.” (030, woman). Some participants explained that experiencing delusional beliefs, to an extent, could reduce their thinking about or attempts at suicide:

“The delusions stopped me from committing suicide. […] I was stopped by delusions saying […] the Nazis would’ve taken you away and that would be worse, so delusions can actually make me behave in this way, but I also had delusions that, for a period of time, stopped me.” (017, man).

Appraising the delusions and hallucinations as having a positive impact protected against suicide-related experiences: “I kept seeing creatures […] them creatures were there to protect me.” (021, woman). It is important to note that these protective hallucinations and delusions were not experienced in isolation. The same individual could have varied psychosis experiences, some of which were perceived to have a protective effect, and others which were distressing: “I would see creatures come to my window that were really horrific. They looked like they were made from charcoal, the whole skin; about four feet tall, red fire socket as eyes.” (021, woman). Despite some positive experiences, psychosis was perceived to be immensely distressing and had a tremendous, negative impact on the individual, which made them feel suicidal: “They’ve [delusions] affected it [my life] tremendously. I still think this guy is after me. […] It made me suicidal.” (019, man).

Theme 2: Changes in Behaviors and Appraisals of Self

The immensely distressing psychosis experiences resulted in negative perceptions of the self and profound doubting of core beliefs held by participants: “I lost confidence in my job and myself as well.” (019, man). For example, some individuals felt responsible for their psychosis. This sense of responsibility resulted in self-blame and feelings of worthlessness caused by the derogatory voices which made participants to not want to be here anymore: “Sometimes I feel like it’s my fault, everything’s my fault that this is happening, so, it makes me feel worthless.” (021, woman).

Some individuals reported feeling social shame in relation to certain delusional beliefs that they held about themselves, which made them feel suicidal:

“…these ideas that I was poisoning everybody, I thought, ‘Oh my God, I’m going to be in the papers, I’m going to be plastered all over Facebook!’ and I thought, I can’t face it and I want to die. I really, really wanted to die.” (030, woman).

As a consequence of the distressing psychosis experiences, participants began to isolate themselves from others and keep away from social interactions by choice, in order to avoid anticipated potential distress in relation to paranoid beliefs: “I felt the people I used to go out with were now against me, part of this conspiracy. So, I don’t go out with them.” (019, man). People were isolating themselves from others due to concerns about being judged for experiencing psychosis:

“…I just switched off from everybody. […] you don’t want to be around people, you’re scared of what you might think or what they might think of you.” (021, woman).

It was not only people’s appraisals of themselves, which were making them feel suicidal. Sometimes suicidality was a direct cause of hearing derogatory voices:

“I would hear all the voices, ‘You’re useless, you’re a piece of shit, you’re a dick, you’re a slag.’ […] And I was just sat there crying, thinking I would kill myself […] I just have that feeling where I just don’t want to be here. I want it all to stop, I want it all to end, I’ve had enough.” (021, woman).

In addition to the derogatory voices, other people’s negative appraisals of the participants made them feel judged and embarrassed, which was particularly distressing. Psychosis and suicidality were described as stigmatizing for participants because of the societal perceptions of people with these experiences:

“I slur my words a lot ’cos of the medication […] and it annoys me when they say, ‘Oh, have you been drinking?’ and I don’t know what to say to them ’cos I’ve not been drinking, and I don’t want to tell them I’m on tablets. […] I’m just a bit embarrassed ’cos a bit of a stigma to it, schizophrenia, isn’t it?” (001, man).

“…there is so much stigma about it [suicide] […] a lot of people say, ‘Oh, if you’re going to do it, you’d have done it already’ and they don’t tend to understand that it’s not like a constant, it’s like an up and down feeling.” (052, woman).

Consequently, this lack of understanding as a result of stigma made participants feel isolated from others and excluded from society in a way that made them feel that they no longer belonged: “When I was ill, I was roaming round the streets on my own, shouting at the clouds with nobody to talk to, I dropped out of the social situation.” (017, male). Isolation in these cases was not by choice but a consequence of societal perceptions of mental health problems. The perceived lack of understanding and belonging made people think about suicide:

“I just felt like the world was going on around me and I wasn’t part of it anymore, and that if I wasn’t here anymore, then it’d be fine because it’d just carry on. So, why should I keep putting myself through this every day when it wouldn’t matter if I wasn’t alive anyway?” (025, woman).

Theme 3: Suicidality as a Means of Escaping Distress

The immense distress which was fueled by psychosis, changes in behaviors and appraisals of self, led participants to want to escape and sometimes left them feeling that they had no other choice but to attempt suicide or self-harm. Some participants reported that they could hear voices telling them to take their own life, which was particularly distressing: “…he [the voice] commanded me to take my own life. He was telling me, ‘To please me now, you’re going to have to end your own life.’ […] it wasn’t very pleasant.” (025, woman). Complying with those voices by self-harming, even though maladaptive, was sometimes the only way to obtain emotional relief from the psychological distress: “…they [the voices] tell me to slash my wrists […] So, sometimes I just do it. It’s the only way they stop.” (057, woman). Participants explained that self-harm was not a way to take their own life but a way to appease the voices: “When I cut myself, I don’t do it to commit suicide. I do it as a relief to the voices and I concentrate on that pain instead of the voices. It blocks them out a bit.” (029, man).

Suicide was viewed as a way to escape distress, which was perceived to have taken over participants’ lives: “I was hopeless to choose anything else but death… There was no hope left other than suicide.” (022, man). Following a prolonged period of experiencing immense psychological distress, attempting suicide was perceived to be the only way to escape:

“That was my decision, to kill myself, to stop the thing, to keep my free will… I was exercising my free will as a man, to kill myself and take away the option that these beings, or whatever it was, had over me.” (022, man).

Having a suicide plan, in case they could no longer cope with the immense distress, could provide a temporary relief: “I’ve got a plan now. I’ll always have that plan as a back-up just in case something happened.” (019, man). However, fear of the consequences of a suicide attempt was a concern for the participants. For example, potential physical disability and being in a worse position as a result of a suicide attempt prevented some people from attempting suicide: “Suppose if I’m crippled and didn’t die, and I was a cripple all my life. If you throw yourself off a bridge, there’s no guarantee it will kill you, is it?” (019, man).

Discussion

This study examined the impact of psychosis on suicidal thoughts and behaviors from the perspectives of individuals with schizophrenia and non-affective psychosis. There are 2 important and novel contributions of this study. The first one is the emphasis on the profound, deleterious impact of psychosis on individuals’ wellbeing, which led to suicidal thoughts and behaviors. Importantly, experiencing psychosis was perceived as immensely distressing. Associations between psychosis, distress, and suicidality have been reported in previous studies using quantitative methodologies,^11,24–28 but people’s views on the specific sources of distress and its impact on suicidal thoughts and behaviors have been inadequately researched.²⁹ A qualitative study using phenomenological analysis examined the perceptions of suicidal ideation in people with schizophrenia.³⁰ Feelings of inferiority, solitude, and inability to relate to others were reported to be associated with suicidal ideation. Those results converge with the feelings of worthlessness and isolation reported in the current study. However, appraisals of the impact of specific psychosis symptoms on suicidality were not investigated in the former study.³⁰ The isolation and worthlessness experienced as a result of psychosis, coupled with the immensely distressing delusions and hallucinations led to a vicious cycle from which a suicide attempt was seen as the only way of escaping.

The second, novel contribution relates to the potential protective effect of certain psychosis experiences against suicidality. Although this study identified a clear link between psychosis, distress, and increased suicidal thoughts and behaviors, the participants reported that specific delusions, such as grandiosity, reduced the likelihood of thinking about or attempting suicide. It is important to note that it is the subjective appraisal of the relentless psychosis-related intrusions that were perceived to weaken or amplify suicidal thoughts and behaviors and the associated psychological distress. There is evidence for inverse associations between delusions and suicidal experiences in the extant literature. For example, experiencing delusions of reference, persecution and grandiosity, and a reduced risk of suicide attempts and death have been reported in 2 studies using quantitative methods.^24,31 Furthermore, a meta-analysis identified auditory hallucinations and delusions to be inversely associated with the risk of suicide death.⁹ However, these findings were based on only 3 studies, 2 of which included poorly described control groups.⁹ Furthermore, these studies were highly heterogenous, making the evidence less robust.⁹ These studies have used quantitative methodological designs to assess the relationships between psychosis symptoms and suicidal experiences, which could have yielded different results, compared to studies using qualitative methods. Nevertheless, the findings have clear clinical applications for interventions that aim to reduce the rate of suicidal experiences in people with schizophrenia. Considering the divergent findings in the literature, careful assessment and understanding of the nature of psychosis on an individual level is necessary to fully explain the links between specific types of delusions and hallucinations and different suicidal experiences. Furthermore, theoretical models of suicide incorporating the impact and appraisals of specific psychosis symptoms on the development of suicidal thoughts and behaviors is warranted. Although many contemporary psychological models of suicide are transdiagnostic,^32–35 none of them consider the role of psychosis in the pathways to suicidal thoughts, attempts, and deaths. Factors that are pertinent to specific mental health problems (eg, hallucinations as part of psychosis) but also operate across mental health problems (eg, psychological distress, low self-esteem) should be included in such models.³⁶

The current study also found that having a suicide plan and self-harming provided, to an extent, temporary emotional relief from psychological distress. Having a suicide plan is associated with more lethal suicide attempts and a greater suicide risk and is, therefore, considered a clinical emergency.^37–39 Participants in this study reported that the unbearable fear of the consequences of their beliefs (eg, being prosecuted and imprisoned) was a reason for having a suicide plan. In those cases, the suicide plan provided a relief from the distressing anticipation of a future event, which was a potential precipitant of the enactment of the suicide plan. Self-harm was perceived as a way to appease the immensely distressing hallucinatory voices. Escape from negative emotions and immediate relief of negative feelings following self-harm have been reported previously.^40–42 Despite this type of temporary emotional relief, self-harm can lead to increased psychological distress and rumination in the long term.⁴³ Self-harm and planning a suicide attempt have been associated with depression, hopelessness, mortality and recurring suicidal behaviors.^44–46 Therefore, the role of both self-harm and planning a suicide attempt on the enactment of those plans clearly needs further investigation to ultimately inform the design of effective suicide prevention interventions.

Strengths and Limitations

There are 4 key strengths of the current study. First, a rigorous qualitative methodological approach was employed. Research investigating the perceived impact of psychosis on suicidal experiences has tended to rely on quantitative measures which were predetermined by clinicians or researchers.⁴⁷ This limits the level of detail of understanding the psychological mechanisms underlying suicidality. Asking individuals about the experiences they perceived as contributing to suicidal thoughts and behaviors ensured that key precursors, which were deemed important to the individual, were examined. Second, the contributions of a group of people with experiences of suicidality to the design of the study should be noted. This results in research that has a genuine impact from scientific, lay public, and clinical practice perspectives.⁴⁸ Third, the study involved a diverse sample of individuals of different ages, diagnoses, and length of contact with mental health services, which contributed to the richness of the data. Fourth, the study proposed a practical heuristic that can enable professionals and researchers to understand the impact of and relationships between psychosis and suicidal thoughts and behaviors.

There were 2 limitations of the current study, which must be taken into consideration. First, participants were recruited from the North of England. This region has the highest number of people in contact with mental health services in England,⁴⁹ which may suggest overrepresentation of the sample. Second, the study relied on accounts of suicidal thoughts and behaviors that, for most, had occurred months or years before the interviews. Individual reports could be influenced by the saliency and recency of events and the proposed heuristic may not capture the full range of ways psychosis impacts in the moment of suicidal thoughts and behaviors. However, including individuals in the sample whose suicide experiences were not current allowed for people’s reflections on their paths to suicidality over time since the suicidal crisis had occurred, which may have enabled the discovery of a range of protective and precipitating factors.

Clinical Implications

There are 4 clinical implications of this study. First, this study can help identify points of intervention that were directly informed by participants’ experiences of psychosis and suicidality and included in a practical heuristic (figure 1). Experiencing psychosis was reported as immensely distressing. Efforts to develop interventions that target understanding and reducing psychological distress in relation to psychosis are of paramount importance.^50,51 Second, participants attributed their suicidal thoughts and behaviors to experiencing distress in relation to psychosis, isolation, and worthlessness, which were fueled by derogatory voices, visions, and delusional beliefs. Therefore, it is essential for clinicians to consider the perceived impact of these factors as key precursors to suicidal thoughts and behaviors. Understanding individuals’ appraisals of self and their mental health problems may help optimize suicide prevention initiatives.⁵² Third, having a suicide plan and self-harming were reported as a means of escaping the immense psychological distress. Providing people with alternative ways of coping with distress, such as developing a sense of control or agency, is a clear treatment target. Fourth, participants reported specific delusions that were perceived to reduce suicidal experiences. There is no consensus regarding the role of certain positive symptoms of psychosis in protecting against the development of suicidal thoughts or behaviors. Hence, individual-specific symptoms perceived to be reducing or increasing the severity of suicidal experiences should be carefully monitored.

Conclusion

The results emphasized the importance of considering psychosis experiences and self-appraisals as precursors to suicidal thoughts and behaviors, and as a source of immense psychological distress. Therefore, minimizing the tremendous psychological pain associated with relentless psychosis experiences is of paramount importance for clinical practice. It is necessary to explore aspects of psychosis, in order to assess the possibility of suicide outcomes, as certain aspects can have an amplifying or a weakening effect on suicidality. The current study proposed a potential practical heuristic of participants’ experiences of psychosis and suicidal thoughts and behaviors, including 3 elements, namely, psychosis as immensely distressing, changes in behaviors and appraisals of self, and suicide as a means of escaping immense psychological distress. The first 2 elements formed a vicious cycle where suicide was perceived to be the only way to escape distress.

Appendix 1. Interview Topic Guide

The following 2 sets of questions and prompts serve as an interview guide.

1. Psychosis symptoms:

   • Can you tell me about your mental health problems/issues?

   • What sort of symptoms do/did you experience?

   • How are/did those affect(ing) your life?

2. Experiences of suicidal thoughts/behaviors:

   People sometimes tell us that they can also feel suicidal or sometimes act on suicidal thoughts:

   • Have you ever felt suicidal?

   • What do you think triggered your suicidal thoughts?

   • What happens to you (mentally and physically) when you have suicidal thoughts?

   • Have you ever attempted to take your own life?

   • What do you think triggered your suicide attempt?

   • Is there anything in particular that caused you to transition from suicide ideas to concrete plans and acts?

End of interview

Funding

The study was supported by Mental Health Research UK and the Schizophrenia Research Fund. The sponsor had no input into the study design, in the collection, analysis, and interpretation of data, in the writing of the report; or in the decision to submit the paper for publication. The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication.