Anestis et al. 373 et al..1991)to less than 30 min had develoned a suicide plan prior to their attemnt this find (e.Woinar et al 2008).to less than 7 consecutive davs ing could indicate that some individuals spend extensive prior to the attempt(e.g..Conner et a2006).Others con- sider the use of easily accessible means or locations clos 0022 s scenario,an ex ensively planne attemp imity to home is an indicator of an impulsive attempt is par viduals are asked to consider only the moments immediatel ticularly problematic.O'Donnell and colleagues (1996) prior to an attempt,without noting the possibility that ther noted that the vast majority of attempis n ther smple of 2 veloped over me and 1,57 rticinants responding to a telenhone su that these attempts were thus impulsive.Inherent in this didalswihapiorhisionyofsuicidalbethaiorcpcn tha We contend that the very nature of suicidal behavior is fluctuated irregularly prior to their attempt,and ony.% such that little to none of it can truly be conceptualized as reported experiencing no previous suicidal ideation or plan prior to their attempt.Furthermore,in a sample of 105 co es2009 er a su cal pain;Jobes,2006)which requires effortful thought Thus,for suicidal behavior tobe impulsive,it 50%of their sample.However,when assessing suicidal pro he at mo theyd participants ab ut the first cur of thoughts that developed episodically over time rather tha building on one another increasingly over time.These meth odological concems raise an issue regarding the precise not be label an earch tha iods。 the intention of the behavior.To inflict serious enough self. the behavior itself by (a)asking participants to spe ifically they are going to and h ing to do it. the petir imn ately prece atten ents'an spur require much planning and has a high probability of resulting eswere spent planning,thereby priming the individual to the boundary think only about hort me ming a pe the equence that behavior.he or she should not need to reeat this pro he fear of death and massive bodily harm and,as such,we cess immediately prior to the behavior for it to be consid pulsively decide to pick up ere d planned and ntal and/orp to ical gcnenagy For example, those fears sidering the contextual factors that could affect their decision to utilize one approach versus other options.Yet,when sur- Obstacles in Studies Examining Impulsivity of icalPproe Attembts Further complicating the conceptualization of impulsivity as tary,and perhaps impulsive,decision rather than the result it applies to suicidal behavior is a tenden y for studies to ces 1%g or prev the by Conner and colle s(2006)were considered impuls despite the fact that 58%of attempters indicated that they may well be.Anestis et al. 373 impulsive” (e.g., Brown et al., 1991) to less than 30 min (e.g., Wojnar et al., 2008), to less than 7 consecutive days prior to the attempt (e.g., Conner et al., 2006). Others con￾sider the use of easily accessible means or locations close to home as evidence of impulsivity (e.g., Conwell et al., 2002; O’Donnell, Farmer, & Catalan, 1996). The use of close prox￾imity to home is an indicator of an impulsive attempt is par￾ticularly problematic. O’Donnell and colleagues (1996) noted that the vast majority of attempts in their sample of 20 attempters who survived jumping in front of a train occurred at the station nearest to the attempter’s home and concluded that these attempts were thus impulsive. Inherent in this viewpoint is the notion that planning a suicide attempt is positively correlated with distance from home, a point that lacks a clear rationale. We contend that the very nature of suicidal behavior is such that little to none of it can truly be conceptualized as impulsive. Although people engage in suicidal behavior for many reasons, they likely boil down to finding a solution to a very serious problem (e.g., ending unbearable psychologi￾cal pain; Jobes, 2006), which requires effortful thought. Thus, for suicidal behavior to be impulsive, it must occur in the absence of prior planning outside the moments and hours immediately preceding the behavior (i.e., consideration of methods and selecting the one to use). Even if the bulk of the planning occurs sporadically over an extended period long before the attempt and minimally or not at all immediately prior to the attempt, then the behavior should not be labeled impulsive. We are proposing a distinction that accounts for the intention of the behavior. To inflict serious enough self￾harm to risk death, people must give very careful thought to what they are going to do and how they are going to do it. A counter-argument could be made that picking up a gun, pointing it at the body, and pulling the trigger does not require much planning and has a high probability of resulting in death without causing pain. In this sense, the boundary typically presented by overcoming pain and a potentially lengthy experience of pain is removed. However, the pros￾pect of shooting oneself nonetheless involves overcoming the fear of death and massive bodily harm and, as such, we believe an individual could impulsively decide to pick up a gun, but would be unable to pull the trigger without enough rehearsal (mental and/or physical) and planning to diminish those fears. Obstacles in Studies Examining Impulsivity of Attempts Further complicating the conceptualization of impulsivity as it applies to suicidal behavior is a tendency for studies to refer to some attempts as impulsive regardless of previous ideation or planning. For instance, 51% of attempts in a study by Conner and colleagues (2006) were considered impulsive despite the fact that 58% of attempters indicated that they had developed a suicide plan prior to their attempt. This find￾ing could indicate that some individuals spend extensive periods of time planning but experience intermittent periods of ideation. In this scenario, an extensively planned attempt may be preceded by a period of mild or even no ideation. In this sense, the findings would be driven by the fact that indi￾viduals are asked to consider only the moments immediately prior to an attempt, without noting the possibility that their thoughts developed over time and were episodic in nature. Indeed, de Leo et al. (2005) found that, in a sample of 11,572 participants responding to a telephone survey, only 20% of individuals with a prior history of suicidal behavior experi￾enced risk as a phenomenon that developed consistently and without break, increasing in severity from the beginning to the end. In fact, 57.1% reported that their “suicidal process” fluctuated irregularly prior to their attempt, and only 0.8% reported experiencing no previous suicidal ideation or plan prior to their attempt. Furthermore, in a sample of 105 con￾secutive patients admitted to an Austrian hospital after a sui￾cide attempt, Deisenhammer and colleagues (2009) reported that the “suicidal process” lasted less than 10 min for nearly 50% of their sample. However, when assessing suicidal pro￾cess, they asked participants about the “first current emer￾gence of suicidal thoughts,” thereby precluding measurement of thoughts that developed episodically over time rather than building on one another increasingly over time. These meth￾odological concerns raise an issue regarding the precise meaning of an impulsive attempt: Research that measures impulsivity of attempts often overlooks extensive periods of planning and consideration that do not immediately precede the behavior itself by (a) asking participants to specifically consider the period immediately preceding the attempt and (b) framing the time period in a manner that might spuriously influence respondents’ answers (e.g., asking how many min￾utes were spent planning, thereby priming the individual to think only about a short time frame). If a person already understands the consequences of engaging in a behavior and the steps required to engage in that behavior, he or she should not need to repeat this pro￾cess immediately prior to the behavior for it to be consid￾ered planned and non-impulsive. For example, emergency surgeons spend countless hours developing expertise at spe￾cific components of particular surgical procedures and con￾sidering the contextual factors that could affect their decision to utilize one approach versus other options. Yet, when sur￾geons are involved in an actual emergency surgical proce￾dure, their decisions often appear automatic, as if their decision to choose a particular option reflected a momen￾tary, and perhaps impulsive, decision rather than the result of a deliberate process involving practice, prior experiences, and thoughtful planning. Here again, the clinical implica￾tions must be noted, as unplanned behaviors may not be pre￾ventable, but behaviors planned long before their enactment may well be. Downloaded from psr.sagepub.com at Remen University of China on September 6, 2015