Anestis et al. 367 alization b the relentless will to remain alive goiner 2010)Should such models prove untrue however the implication would Relatedly,Baumeister (1990)proposed that suicide be that,to override the drive to survive,an individual id an escape I would n to chip away er time.In this e,we ulses to engage in suicidal hehavior while lethal or such a state and.as a result.become increasingly at risk for substantial planning.Although further research testing engaging in such behavior impulsively.Similarly,some mportant components of this model is needed,we argue believet yserves as the diati every etfort to test it thus tar has been supportive posing suicidal behavior is frequently impulsiveis enact lethal self-harm (e.g.,Mann,Waternaux. Haas, problematic. Malone,1999).In this cor ptualization,suicidal behavior i The promin ence of models that describe suicida ewed as un anne est see individuals who display a general tendency to act without impulsive suicidal behavior Conner et a 207:de forethought.Indeed,in explaining the role of impulsivity in Leo,Cerin,Spathonis,Burgis,2005:Mann et al..1996) suicidal ehavior, ann et al.(1)noted that,due to th have typically prope on fee L: picmehdsimcteodhrcTahr ridual or the deg behavior were engaged in impulsively.We argue that the onse to affect in people nature o fthe measures and the designs used in such inves who a ave pre d res ningand impulsive action are not mutually exclusive.sta pretations of published data have resulted in erroneous 582 This ses questions regarding conclusion In addition,we argue that a failure to con ne den ty,as a b e mo ast many common of the construct (e.g sively.The pu se of this review is to consolidate find In this review,the focus is on ings discuss their cations and limitations and vity that the ten cal framew ch of the ribed is the beha notion that people often engage in suicidal behavior with To accomplish these goals.our article is divided into three signif and e In the provide a met state thought is regularly noted as a stater t of fact in liter reviews.For instance. and colle gues (2010)cited a act impu of studie ew,noting th ely ly a cent d tha step beha are unplanned(p.275).Inherent in this viewpoint is the nitude of this assoc iation into belief that suicidal behavior frequently occurs without any a clearer rstanding risk fa sistent defini of im icida behavior and the role of elinicians in identifying and miti- or problematic meas urements of planning,and a pa gating risk (A.R Smith et al..2008) tern of results incompatible with the notion that f an indi eng idal beha with to th cognitive states are canable of ove our alternative con entualization of the association hetwee coming what many would argue is a fundamental impulsivity and suicidal behavior and the empirical evidence component of human nature and an evolutionary imperative underlying that conceptualization.Anestis et al. 367 conceptualization have not been consistently supportive (e.g., Roggenbach, Muller-Oerlinghausen, & Franke, 2002). Relatedly, Baumeister (1990) proposed that suicide attempts represent an escape from aversive self-awareness and that individuals develop a diminished ability to resist impulses to engage in suicidal behavior while experiencing such a state and, as a result, become increasingly at risk for engaging in such behavior impulsively. Similarly, some believe that impulsivity serves as the diathesis in a diathesis￾stress model in which stressors such as negative life events might interact with impulsivity to result in rash efforts to enact lethal self-harm (e.g., Mann, Waternaux, Haas, & Malone, 1999). In this conceptualization, suicidal behavior is viewed as a frequently unplanned behavioral response to momentary aversive experiences, more likely to occur in individuals who display a general tendency to act without forethought. Indeed, in explaining the role of impulsivity in suicidal behavior, Mann et al. (1999) noted that, due to their propensity toward impulsive action, suicide attempters “feel more suicidal and are more likely to act on feelings” (p. 186). Implicit in such a statement is the notion that suicidal behav￾ior often emerges explosively in response to affect in people who are less capable of inhibiting rash responses to sudden urges. In addition, the same researchers proposed that plan￾ning and impulsive action are not mutually exclusive, stating that “the decision to act on a careful plan may be impulsive” (Mann et al., 1996, p. 582). This raises questions regarding the definition of impulsivity, as a decision to act on a plan previously developed in great depth seems to directly con￾trast many common conceptualizations of the construct (e.g., Whiteside & Lynam, 2001). In this review, the focus is on conceptualizations of impulsivity that emphasize the ten￾dency to act without forethought. A theme across each of the theories just described is the notion that people often engage in suicidal behavior with￾out significant planning and that suicide attempts are often fueled by intense affective states. Indeed, the notion that suicidal behavior frequently occurs with little to no fore￾thought is regularly noted as a statement of fact in literature reviews. For instance, Jeon and colleagues (2010) cited a number of studies detailed later in this review, noting that “with respect to the literature, studies have consistently reported that a considerable proportion of suicidal attempts are unplanned” (p. 275). Inherent in this viewpoint is the belief that suicidal behavior frequently occurs without any detectable progression from low to imminent risk. This supposition has obvious implications with respect to our understanding of risk factors related to imminent suicidal behavior and the role of clinicians in identifying and miti￾gating risk (A. R. Smith et al., 2008). If an individual can engage in suicidal behavior without prior consideration, this speaks to the notion that momen￾tary affective and/or cognitive states are capable of over￾coming what many would argue is a fundamental component of human nature and an evolutionary imperative: the relentless will to remain alive (Joiner, 2010). Should such models prove untrue, however, the implication would be that, to override the drive to survive, an individual would need to chip away at it over time. In this article, we present an alternative model that argues that little, if any, suicidal behavior—lethal or non-lethal—occurs without substantial planning. Although further research testing important components of this model is needed, we argue that every effort to test it thus far has been supportive, whereas evidence that purportedly supports models pro￾posing suicidal behavior is frequently impulsive is problematic. The prominence of models that describe suicidal behavior as frequently impulsive is perhaps best seen through the frequent (and highly cited) efforts to measure impulsive suicidal behavior (e.g., Conner et al., 2007; de Leo, Cerin, Spathonis, & Burgis, 2005; Mann et al., 1996). Such studies have typically approached the association from one of two angles: the trait impulsivity of the indi￾vidual or the degree to which specific acts of suicidal behavior were engaged in impulsively. We argue that the nature of the measures and the designs used in such inves￾tigations have precluded researchers from directly testing models that propose that suicidal behavior is frequently impulsive (see Figure 1a). Furthermore, we believe inter￾pretations of published data have resulted in erroneous conclusions. In addition, we argue that a failure to con￾sider plausible alternative models fully has fueled the belief that suicidal behavior frequently occurs impul￾sively. The purpose of this review is to consolidate find￾ings, discuss their implications and limitations, and propose a new theoretical framework from which to con￾sider the relationship between impulsivity and suicidal behavior (see Figure 1b). To accomplish these goals, our article is divided into three separate sections. In the first section, we provide a meta￾analysis that examines the strength of the relationship between trait impulsivity and suicidal behavior. We antici￾pate that this relationship will be small in magnitude, thereby highlighting the point that a general tendency to act impul￾sively is unlikely a central component of suicidal behavior. This analysis represents a critical first step in considering the relationship between impulsivity and suicidal behavior and the results could place the magnitude of this association into a clearer context. In the second section, we provide a critical review of literature examining the impulsiveness of specific suicide attempts. We show that the general pattern of find￾ings reveals inconsistent definitions of impulsive suicidal behavior, problematic measurements of planning, and a pat￾tern of results incompatible with the notion that suicidal behavior frequently occurs without extensive planning. In the final section of the article, we provide a description of our alternative conceptualization of the association between impulsivity and suicidal behavior and the empirical evidence underlying that conceptualization. Downloaded from psr.sagepub.com at Remen University of China on September 6, 2015