Validation and psychometric properties of the German Capability for Suicide Questionnaire
Introduction
In 2011, 10 144 people died of suicide in Germany, overall; this accounts for an average of 12.4 suicidal deaths in 100,000 inhabitants [1]. Data for the U.S. population is similar—a death rate of 12.3 per 100,000 population is reported [2]. The number of suicide attempts is estimated to be up to 20 times higher than the number of actual deaths [3]. Furthermore, adults are reported to have a lifetime prevalence of 6% to 14% of experiencing suicidal ideation [4]. Ninety percent of all suicides are committed by individuals, who suffer from a mental illness [5], most prominently affective disorders, schizophrenia, borderline personality disorder, anorexia nervosa and substance abuse [6], [7]. Other known risk factors include male gender, older age, social isolation, family conflict, unemployment and physical illness [8], [9]. Overall, very few patients suffering from one of the conditions listed above, displaying another suicide risk factor or reporting suicidal ideation actually commit suicide. Therefore, a central question arises: Who of those at risk or contemplating suicide actually attempt or even die by suicide? Furthermore, it is of interest which intra- and interpersonal processes play a role in suicidal behaviors.
Joiner [8] makes an effort to answer these questions by proposing the interpersonal theory of suicide (IPTS). He states that one's wish to die is not sufficient for a serious or lethal attempt. Additionally, one also has to have the ability to overcome one's fear of death and to tolerate the pain that accompanies a suicide attempt. Consequently, two conditions—a death wish and the acquired capability to commit suicide—are jointly leading to a suicide attempt.
According to Joiner [8], two psychological conditions—perceived burdensomeness and thwarted belongingness—together result in a wish to die. Perceived burdensomeness refers to the subjective conviction to be a burden on family, friends or society in general and the thought that others would be better off without oneself [8]. Thwarted belongingness is defined as one's impression of not belonging to a valued group like a family or a circle of friends. Van Orden and colleagues [9] state that both loneliness and the absence of reciprocal care contribute to the sense of thwarted belongingness. Various studies have verified that perceived burdensomeness, thwarted belongingness and most importantly the joint occurrence of both psychological states are predictive of suicidal ideation [10], [11]. Finally, Joiner [8] proposes that people thinking of and wishing to commit suicide and those who actually make an attempt to take their own life are differentiated by their extent of acquired capability. People who possess acquired capability are supposed to show both higher tolerance for physical pain and a lower fear of death. These preconditions are assumed to enable suicidal persons to tolerate whichever pain is involved in a suicidal act and to overcome their fear of death-threshold. According to Joiner [8], people acquire the capability to commit suicide by making repeated physically painful and/or frightening experiences such as drug application, combat experiences, sexual or physical abuse, deliberated self-harm, extreme sports etc. Furthermore, certain personality traits such as impulsivity or sensation seeking supposedly contribute to the acquisition, as people who display those traits are more likely to face painful and provocative events [12], [13]. The most direct route to acquire this capability, though, is to execute suicidal behaviors such as former suicide attempts, to prepare for an attempt or through cognitive preoccupation such as daydreaming about it [9]. Two mechanisms are supposed to be at play here—habituation and opponent processes [14]. It is assumed that by making painful and provocative experiences a person's fear threshold is lowered and physical pain will be more easily tolerated. Once acquired, the capability for suicide is thought to remain stable and not to be “reversible” [8]. A number of studies show that higher levels of acquired capability are indeed associated with higher numbers of past suicide attempts in patients [15], [16] and soldiers [17], [18]. Furthermore, acquired capability significantly predicted suicide risk in an autopsy study with Air Force personnel who had died by suicide [19]. Another study revealed that a higher extent of acquired capability was significantly associated with pain tolerance as measured with a cold pressor task (r = .40, p < .001; [20]). However, all studies conducted so far are limited by their cross-sectional design; up to now it has not been possible to determine the causal association of suicidal behavior and acquired capability.
To assess a subject's extent of acquired capability, Joiner and colleagues [7] presented the Acquired Capability for Suicide Scale (ACSS) comprising 20 items. In order to determine the ACSS' factor structure, Smith et al. [21] performed an exploratory factor analysis on the questionnaire. They retrieved three interpretable factors: “General Fearlessness & Perceived Pain Tolerance,” “Fearlessness of Death” and “Spectator Enjoyment of Violence.” This factor structure differs from what one would have expected of the ACSS, namely a two-factor structure including a factor representing pain tolerance and another one representing fearlessness about death. Furthermore, none of the derived factors proved to be able to differentiate suicide attempters from non-attempters. Ribeiro and colleagues [22] offered a revision of the ACSS just recently and presented the “Fearlessness about Death” scale (ACSS-FAD) consisting of seven items. The scale had an adequate to good internal consistency (α ranging from 0.77 to 0.85) as well as a good construct validity—for example, a highly significant positive association was found with a measure of fear of suicide (−.45, p < .01). Overall, the scale proved to be a viable measure of subjects' extent of fearlessness of death. Items assessing pain tolerance, on the other hand, were not identified. Altogether, a validated version of the ACSS measuring both fearlessness of death and pain tolerance is still lacking.
In a pilot study, the psychometric properties of a German translation of the ACSS [23] were examined in a non-clinical sample of 191 adults. Since hockey is a fringe sport in Germany, item 16 of the original ACSS (“The best parts of hockey games are the fights”) was excluded from the German version. Six items were found to load onto one factor with loadings ranging from .59 to .92. The factor was named “Fearlessness of Death” due to the items' content. As a matter of fact, the items are—except for one item (“It does not make me nervous when people talk about death”)—part of the ACSS-FAD. Also, no items assessing pain tolerance were identified and no other meaningful factors were derived from the data. One item, namely item 20 “I could kill myself if I wanted to,” did not load onto the factor “Fearlessness of Death,” but it differentiated well between former suicide attempters and non-attempters [24]. It was named “perceived capability” item. A problem was encountered involving certain items with negative wording (e.g. translation of item 19 “I am not at all afraid to die”) and the Likert scale (1—not at all like me; 5—very much like me). Answering these particular items, subjects were faced with a double negative, which proved difficult to answer. The same problem was reported by Nademin and colleagues [19].
Based on these results and considerations and to overcome the shortcomings of earlier versions, we created—parallel to Ribeiro and colleagues [22]—a new instrument to assess acquired capability, the German Capability for Suicide Questionnaire, the GCSQ. The six items loading onto the factor “Fearlessness of Death” were reworded to exclude negative wording. Two items, namely item 10 (“I am very much afraid to die”) and item 19 (“I am not at all afraid to die”) of the ACSS, were basically the same after they were reworded. Therefore, item 19 was dropped and five items representing the factor “Fearlessness of Death” remained. Overall, the questionnaire comprises 14 items. Five items assess the extent of fear of death. New items were created to assess pain tolerance with their content being rationally derived based on the interpersonal theory's description of pain tolerance as a facet of acquired capability. Furthermore, the items were presented to fellow colleagues for their evaluation of the content, which left us with eight items assessing pain tolerance overall. One item—the “perceived capability” item—that had proven to differentiate well between suicide attempters and non-attempters was furthermore retained as part of the questionnaire. We used a 5-point Likert scale; items 6, 7, 10, 11 and 14 were coded reversely.
The present study's main purpose was to examine the GCSQ's factor structure as well as its reliability, convergent and discriminant validity, predictive validity as well as test–retest reliability. We hypothesized that the questionnaire would have a two-factor structure covering the subject's pain tolerance and extent of fear of death—both facets of acquired capability as suggested by the IPTS. With respect to convergent validity, it was assumed that fearlessness of death and pain tolerance would positively correlate with measures of experiences with painful and provocative events, impulsivity, sensation seeking, suicidal behaviors and an accepting attitude towards one's own dying and death. Negative associations were expected with measures of fear of death and pain sensitivity. With respect to discriminant validity, we expected to not find a significant correlation with suicidal ideation. Van Orden and colleagues [9] state that suicidal ideation emerges when a subject experiences both perceived burdensomeness and thwarted belongingness. People having suicidal thoughts may also show a higher extent of acquired capability; but according to the IPTS suicidal ideation itself is not associated with acquired capability. Furthermore, we hypothesized that our measures of fearlessness of death and pain tolerance are predictive of the subjects' self-reported suicidal behaviors and suicidal attempt status. Finally, we assumed that the questionnaire would show high test–retest reliability, which would be consistent with the IPTS' hypothesis that acquired capability is stable once it is acquired.
Section snippets
Participants
Data were derived from three different samples from a clinical as well as a community setting in Germany. All participants were Caucasian.
- Sample 1
The first sample was a community sample of 532 participants of which 73.7% (n = 392) were female and 26.3% (n = 140) were male. Age ranged from 18 to 83 years with a mean of 34.1 (SD = 15.1). Four hundred ninety-six (93.6%) had never attempted suicide before, whereas 21 (3.9%) had attempted suicide once before and 15 (2.8%) reported multiple attempts. The majority
Factor structure
A principal component analysis with orthogonal rotation (oblimin) was conducted for samples 2, 3, and a subsample of 50% of sample 1 (n = 266) jointly. The sample size amounted to 670 subjects. The Kaiser–Meyer–Olkin measure verified the adequacy of the sample (KMO = 0.82). Bartlett's test of sphericity was significant (χ2 = 4259.79, p < .001) indicating a strong and appropriate relationship among the items. Theory-driven, two factors were derived (see Table 1), which accounted for 47.69% of the total
Discussion
In the present study we investigated factor structure, reliability of the subscales, construct validity, predictive validity and test–retest reliability of the German Capability for Suicide Questionnaire. We found that the GCSQ possesses a two-factor structure with a factor “Fearlessness of Death” and another factor “Pain Tolerance,” which is in accordance with the IPTS. Furthermore, in line with previous studies [24], an item assessing the subject's perceived capability for suicide was
Conclusion
To our knowledge, the GCSQ is the first questionnaire to assess both pain tolerance and fearlessness of death. A validated instrument is of importance, especially when it comes to conducting elaborate, time-consuming and expensive longitudinal studies observing whether subjects with higher acquired capability have a higher incidence of suicidal behaviors including attempted and executed suicides. Future studies need to employ a longitudinal design in order to determine the causal relationship
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2020, Children and Youth Services ReviewCitation Excerpt :The inconsistent results of previous studies are thought to be due to the differences in measures. Acquired capability for suicide is measured by various measures such as The Acquired Capability for Suicide Scale (ACSS; Van Orden et al., 2008), German Capability for Suicide Questionnaire (GCSQ; Wachtel et al., 2014), and Acquired Capability with Rehearsal for Suicide Scale (ACWRSS; George, Page, Hooke, & Stritzke, 2016). Each scale is composed of different sub-factors.
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