Skip to content
Licensed Unlicensed Requires Authentication Published by De Gruyter November 20, 2014

Emotion regulation and adolescent suicide: a proposal for physician education

  • Timothy R. Rice EMAIL logo

Abstract

Suicide is the second leading cause of death among adolescents aged 14–19 years. Pediatricians report strong interest in receiving additional training to reduce suicide mortality, and physician education is one of the most robust means of suicide prevention. However, many studies suggest that existing educational methods and means leave much room for improvement. In light of the emerging evidence that emotion regulation (ER) deficits are significantly associated with adolescent suicide, this paper proposes the untested hypothesis that a module on the brain-based ER system may strengthen existing methods of provider education. The ER system and the evidence supporting its association with adolescent suicide are reviewed. The ability to ground an approach to suicide prevention within this brain-based medical model may be appealing to pediatricians; its transdiagnostic breadth and dimensional makeup may also be appealing to pediatricians. Most importantly, its emphasis on the negative effects of impoverished self-regulation broaden non-specialist concern from a restriction upon withdrawn, depressed adolescents to those with a wide range of psychopathology. Implications and further considerations are discussed.


Corresponding author: Timothy R. Rice, Department of Psychiatry, The Icahn School of Medicine at Mount Sinai, 1 Gustave L Levy Place, Box 1230, New York, NY 10029, USA, E-mail:

References

1. Hamilton BE, Hoyert DL, Martin JA, Strobino DM, Guyer B. Annual summary of vital statistics: 2010-2011. Pediatric 2013;131:548–58.10.1542/peds.2012-3769Search in Google Scholar PubMed PubMed Central

2. Eaton D, Kann L, Kinchen S. Centers for Disease Control and Prevention (CDC) Youth Risk Behavior Surveillance – United States, 2011. MMWR 2012;61:1–162.Search in Google Scholar

3. Frankenfield DL, Keyl PM, Gielen A, Wissow LS, Werthamer L, et al. Adolescent patients – healthy or hurting? Missed opportunities to screen for suicide risk in the primary care setting. Arch Pediatr Adolesc Med 2000;154:162–8.10.1001/archpedi.154.2.162Search in Google Scholar PubMed

4. Fallucco EM, Hanson MD, Glowinski AL. Teaching pediatric residents to assess adolescent suicide risk with a standardized patient module. Pediatrics 2010;125:953–9.10.1542/peds.2009-2135Search in Google Scholar PubMed

5. Taliaferro LA, Borowsky IW. Perspective: physician education: a promising strategy to prevent adolescent suicide. Acad Med 2011;86:342–7.10.1097/ACM.0b013e31820984adSearch in Google Scholar PubMed

6. Mann JJ, Apter A, Bertolote J, Beautrais A, Currier D, et al. Suicide prevention strategies: a systematic review. J Am Med Assoc 2005;294:2064–74.10.1001/jama.294.16.2064Search in Google Scholar PubMed

7. Rice TR, Sher L. Educating health care trainees and professionals about suicide prevention in depressed adolescents. Int J Adolesc Med Health 2013;25:221–9.10.1515/ijamh-2013-0056Search in Google Scholar PubMed

8. Sudak D, Roy A, Sudak H, Lipschitz A, Maltsberger J, et al. Deficiencies in suicide training in primary care specialties: a survey of training directors. Acad Psychiatry 2007;31:345–9.10.1176/appi.ap.31.5.345Search in Google Scholar PubMed

9. Habis A, Tall L, Smith J, Guenther E. Pediatric emergency medicine physicians’ current practices and beliefs regarding mental health screening. Pediatr Emerg Care 2007;23:387–93.10.1097/01.pec.0000278401.37697.79Search in Google Scholar PubMed

10. Halpern-Felsher BL, Ozer EM, Millstein SG, Wibbelsman CJ, Fuster CD, et al. Preventive services in a health maintenance organization: how well do pediatricians screen and educate adolescent patients? Arch Pediatr Adolesc Med 2000;154:173–9.10.1001/archpedi.154.2.173Search in Google Scholar PubMed

11. Klein JD, Allan MJ, Elster AB, Stevens D, Cox C, et al. Improving adolescent preventive care in community health centers. Pediatrics 2001;107:318–27.10.1542/peds.107.2.318Search in Google Scholar PubMed

12. Peña JB, Caine ED. Screening as an approach for adolescent suicide prevention. Suicide Life Threat Behav 2006;36:614–37.10.1521/suli.2006.36.6.614Search in Google Scholar PubMed

13. Pisani AR, Cross WF, Gould MS. The assessment and management of suicide risk: state of workshop education. Suicide Life Threat Behav 2011;41:255–76.10.1111/j.1943-278X.2011.00026.xSearch in Google Scholar PubMed PubMed Central

14. Wintersteen MB. Standardized screening for suicidal adolescents in primary care. Pediatrics 2010;125:938–44.10.1542/peds.2009-2458Search in Google Scholar PubMed

15. Kemper KJ, Foy JM, Wissow L, Shore S. Enhancing communication skills for pediatric visits through on-line training using video demonstrations. BMC Med Educ 2008;8:8.10.1186/1472-6920-8-8Search in Google Scholar PubMed PubMed Central

16. Horwitz SM, Heinberg LJ, Storfer-Isser A, Barnes DH, Smith M, et al. Teaching physicians to assess suicidal youth presenting to the emergency department. Pediatr Emerg Care 2011;27:601–5.10.1097/PEC.0b013e31822255a1Search in Google Scholar PubMed

17. Patten SB. Delicate considerations and blunt instruments. Can J Psychiatry 2014;59:117.10.1177/070674371405900301Search in Google Scholar PubMed PubMed Central

18. Etkin A, Cuthbert B. Beyond the DSM: development of a transdiagnostic psychiatric neuroscience course. Acad Psychiatry 2014;38:145–150.10.1007/s40596-013-0032-4Search in Google Scholar PubMed

19. Insel TR. The NIMH Research Domain Criteria (RDoC) Project: precision medicine for psychiatry. Am J Psychiatry 2014;171:395–7.10.1176/appi.ajp.2014.14020138Search in Google Scholar PubMed

20. Gross JJ. Emotion regulation: conceptual and empirical foundations. In: Groos JJ, editor. Handbook of emotional regulation, 2nd ed. New York: Guilford, 2014:3–20.Search in Google Scholar

21. Oschner KN, Gross JJ. The neural bases of emotion and emotion regulation: a valuation perspective. In: Groos JJ, editor. Handbook of emotional regulation, 2nd ed. New York: Guilford, 2014:23–41.Search in Google Scholar

22. Gross JJ. Emotion regulation: taking stock and moving forward. Emotion 2013;13:359–65.10.1037/a0032135Search in Google Scholar PubMed

23. Insel T, Cuthbert B, Garvey M, Heinssen R, Pine DS, et al. Research domain criteria (RDoC): toward a new classification framework for research on mental disorders. Am J Psychiatry 2010;167:748–51.10.1176/appi.ajp.2010.09091379Search in Google Scholar PubMed

24. Goldin PR, McRae K, Ramel W, Gross JJ. The neural bases of emotion regulation: reappraisal and suppression of negative emotion. Biol Psychiatry 2008;63:577–86.10.1016/j.biopsych.2007.05.031Search in Google Scholar PubMed PubMed Central

25. Dunn BD, Billotti D, Murphy V, Dalgleish T. The consequences of effortful emotion regulation when processing distressing material: a comparison of suppression and acceptance. Behav Res Ther 2009;47:761–63.10.1016/j.brat.2009.05.007Search in Google Scholar PubMed PubMed Central

26. McRae K, Hughes B, Chopra S, Gabrieli JDE, Gross JJ, et al. The neural bases of distraction and reappraisal. J Cogn Neurosci 2010;22:248–62.10.1162/jocn.2009.21243Search in Google Scholar PubMed PubMed Central

27. Ochsner KN, Bunge SA, Gross JJ, Gabrieli JDE. Rethinking feelings: an FMRI study of the cognitive regulation of emotion. J Cogn Neurosci 2002;14:1215–29.10.1162/089892902760807212Search in Google Scholar PubMed

28. Jollant F, Lawrence NL, Olie E, Guillaume S, Courtet P. The suicidal mind and brain: a review of neuropsychological and neuroimaging studies. World J Biol Psychiatry 2011;12:319–39.10.3109/15622975.2011.556200Search in Google Scholar PubMed

29. Kopp C, Neufeld S. Emotional development during infancy. In: Davidson RJ, Scherer KR, Goldsmith HH, editors. Handbook of affective sciences. Oxford: Oxford University Press, 2003: 347–74.Search in Google Scholar

30. Rothbart MK, Sheese BE, Rueda MR, Posner MI. Developing mechanisms of self-regulation in early life. Emot Rev 2011;3:207–13.10.1177/1754073910387943Search in Google Scholar PubMed PubMed Central

31. Calkins SD, Hill A. Caregiver influences on emerging emotional regulation: biological and environmental transactions in early development. In: Gross JJ, editor. Handbook of emotional regulation. New York: Guilford, 2009:229–48.Search in Google Scholar

32. Perlman G, Simmons AN, Wu J, Hahn KS, Tapert SF, et al. Amygdala response and functional connectivity during emotion regulation: a study of 14 depressed adolescents. J Affect Disord 2012;139:75–84.10.1016/j.jad.2012.01.044Search in Google Scholar PubMed PubMed Central

33. Silk JS, Steinberg L, Morris AS. Adolescents’ emotion regulation in daily life: links to depressive symptoms and problem behavior. Child Dev 2003;74:1–2.10.1046/j.1467-8624.2003.00643.xSearch in Google Scholar PubMed

34. Cavanagh M, Quinn D, Duncan D, Graham T, Balbuena L. Oppositional defiant disorder is better conceptualized as a disorder of emotional regulation. J Atten Disord 2014 Mar 13. Epub ahead of print.Search in Google Scholar

35. Stringaris A, Goodman R. Longitudinal outcome of youth oppositionality: irritable, headstrong, and hurtful behaviors have distinctive predictions. J Am Acad Child Adolesc Psychiatr 2009;48:404–12.10.1097/CHI.0b013e3181984f30Search in Google Scholar PubMed

36. Burke JD. An affective dimension within oppositional defiant disorder symptoms among boys: personality and psychopathology outcomes into early adulthood. J Child Psychol Psychiatry 2012;53:1176–83.10.1111/j.1469-7610.2012.02598.xSearch in Google Scholar PubMed PubMed Central

37. Gadow KD, Drabick DAG. Anger and irritability symptoms among youth with ODD: cross-informant versus source-exclusive syndromes. J Abnorm Child Psychol 2012;40:1073–85.10.1007/s10802-012-9637-4Search in Google Scholar PubMed PubMed Central

38. Whelan YM, Stringaris A, Maughan B, Barker ED. Developmental continuity of oppositional defiant disorder subdimensions at ages 8, 10, and 13 years and their distinct psychiatric outcomes at age 16 years. J Am Acad Child Adolesc Psychiatry 2013;52:961–9.10.1016/j.jaac.2013.06.013Search in Google Scholar PubMed PubMed Central

39. Rowe R, Costello EJ, Angold A, Copeland WE, Maughan B. Developmental pathways in oppositional defiant disorder and conduct disorder. J Abnorm Psychol 2010;119:726–38.10.1037/a0020798Search in Google Scholar PubMed PubMed Central

40. Shaw P, Stringaris A, Nigg J, Leibenluft E. Emotion dysregulation in attention deficit hyperactivity disorder. Am J Psychiatry 2014;171:276–93.10.1176/appi.ajp.2013.13070966Search in Google Scholar PubMed PubMed Central

41. Dougherty LR, Smith VC, Bufferd SJ, Carlson GA, Stringaris A, et al. DSM-5 disruptive mood dysregulation disorder: correlates and predictors in young children. Psychol Med 2014;21:1–12.10.1017/S0033291713003115Search in Google Scholar PubMed PubMed Central

42. Shaffer D, Garland A, Gould M, Fisher P, Trautman P. Preventing teenage suicide: a critical review. J Am Acad Child Adolesc Psychiatry 1988;27:675–87.10.1097/00004583-198811000-00001Search in Google Scholar PubMed

43. Negron R, Piacentini J, Graae F, Davies M, Shaffer D. Microanalysis of adolescent suicide attempters and ideators during the acute suicidal episode. J Am Acad Child Adolesc Psychiatry 1997;36:1512–9.Search in Google Scholar

44. Goldston DB, Daniel S, Reboussin DM, Kelley A, Ievers C, et al. First-time suicide attempters, repeat attempters, and previous attempters on an adolescent inpatient psychiatry unit. J Am Acad Child Adolesc Psychiatry 1996;35:631–9.10.1097/00004583-199605000-00018Search in Google Scholar PubMed

45. Pisani AR, Wyman PA, Petrova M, Schmeelk-Cone K, Goldston DB, et al. Emotion regulation difficulties, youth-adult relationships, and suicide attempts among high school students in underserved communities. J Youth Adolesc 2013;42:807–20.10.1007/s10964-012-9884-2Search in Google Scholar PubMed PubMed Central

46. In-Albon T, Bürli M, Ruf C, Schmid M. Non-suicidal self-injury and emotion regulation: a review on facial emotion recognition and facial mimicry. Child Adolesc Psychiatry Ment Health 2013;7:5.10.1186/1753-2000-7-5Search in Google Scholar PubMed PubMed Central

47. Zlotnick C, Donaldson D, Spirito A, Pearlstein T. Affect regulation and suicide attempts in adolescent inpatients. J Am Acad Child Adolesc Psychiatry 1997;36:793–8.10.1097/00004583-199706000-00016Search in Google Scholar PubMed

48. Kienhorst CW, de Wilde EJ, Diekstra RF, Wolters WH. Differences between adolescent suicide attempters and depressed adolescents. Acta Psychiatr Scand 1992;85:222–8.10.1111/j.1600-0447.1992.tb08599.xSearch in Google Scholar PubMed

49. Tamas Z, Kovacs M, Gentzler AL, Tepper P, Gadoros J, et al. The relations of temperament and emotion self- regulation with suicidal behaviors in a clinical sample of depressed children in Hungary. J Abnorm Child Psychol 2007;35:640–52.10.1007/s10802-007-9119-2Search in Google Scholar PubMed

50. Jacobson C, Batejan K, Kleinman M, Gould M. Reasons for attempting suicide among a community sample of adolescents. Suicide Life Threat Behav 2013;43:646–62.10.1111/sltb.12047Search in Google Scholar PubMed

51. Pettit JW, Temple SR, Norton PJ, Yaroslavsky I, Grover KE, et al. Thought suppression and suicidal ideation: preliminary evidence in support of a robust association. Depress Anxiety 2009;26:758–63.10.1002/da.20512Search in Google Scholar PubMed

52. Van Eck K, Ballard E, Hart S, Newcomer A, Musci R, et al. ADHD and suicidal ideation: The roles of emotion regulation and depressive symptoms among college students. J Atten Disord 2014 Jan 27. Epub ahead of print.10.1177/1087054713518238Search in Google Scholar PubMed

53. Forkmann T, Scherer A, Böcker M, Pawelzik M, Gauggel S, et al. The relation of cognitive reappraisal and expressive suppression to suicidal ideation and suicidal desire. Suicide Life Threat Behav 2014 Feb 3. Epub ahead of print.10.1111/sltb.12076Search in Google Scholar PubMed

54. Rice TR, Sher L. Educating non-mental healthcare providers about suicide-risk assessment in adolescents. Neuropsychiatry (London) 2012;2:267–70.10.2217/npy.12.33Search in Google Scholar

55. Sher L. Teaching medical professionals about suicide prevention: what’s missing? Q J Med 2011;104:1005–8.10.1093/qjmed/hcr125Search in Google Scholar PubMed

56. Sher L. Teaching medical professionals and trainees about adolescent suicide prevention: five key problems. Int J Adolesc Med Health 2012;24:121–3.10.1515/ijamh.2012.018Search in Google Scholar PubMed

57. Gyurak A, Etkin A. A neurobiological model of implicit and explicit emotion regulation. In: Gross JJ, editor. Handbook of emotional regulation, 2nd ed. New York: Guilford, 2014:203–18.Search in Google Scholar

58. Gyurak A, Gross JJ, Etkin A. Explicit and implicit emotion regulation: a dual-process framework. Cogn Emot 2011;25:400–12.10.1080/02699931.2010.544160Search in Google Scholar PubMed PubMed Central

59. Koole SL, Rothermund K. “I feel better but I don’t know why”: the psychology of implicit emotion regulation. Cogn Emot 2011;25:389–99.10.1080/02699931.2010.550505Search in Google Scholar PubMed

60. Ehring T, Tuschen-Caffier B, Schnülle J, Fischer S, Gross JJ. Emotion regulation and vulnerability to depression: spontaneous versus instructed use of emotion suppression and reappraisal. Emotion 2010;10:563–72.10.1037/a0019010Search in Google Scholar PubMed

61. Etkin A, Prater KE, Hoeft F, Menon V, Schatzberg AF. Failure of anterior cingulate activation and connectivity with the amygdala during implicit regulation of emotional processing in generalized anxiety disorder. Am J Psychiatry 2010;167:545–54.10.1176/appi.ajp.2009.09070931Search in Google Scholar PubMed PubMed Central

62. Rice T, Hoffman L. Defense mechanisms and implicit emotion regulation: a comparison of a psychodynamic construct with one from contemporary neuroscience. J Am Psychoanal Assoc 2014;62:693–708.10.1177/0003065114546746Search in Google Scholar PubMed

Received: 2014-7-3
Accepted: 2014-8-17
Published Online: 2014-11-20
Published in Print: 2015-5-1

©2015 by De Gruyter

Downloaded on 7.5.2024 from https://www.degruyter.com/document/doi/10.1515/ijamh-2015-5010/html
Scroll to top button