|Year : 2021 | Volume
| Issue : 1 | Page : 51-56
Defeat and entrapment in the pathogenesis of suicidal behavior
Srikrishna Nukala1, Srinivas Singisetti2, Archana Vinnakota3, Shvetha Chilikuri2, Abhilash Garapati4, Vidya Sanapala4, Laxman Nambaru5
1 Professor and HOD, Department of Psychiatry, Gitam Institute of Medical Sciences and Research, Visakhapatnam, Andhra Pradesh, India
2 Assistant Professor, Department of Psychiatry, Gitam Institute of Medical Sciences and Research, Visakhapatnam, Andhra Pradesh, India
3 Associate Professor, Department of Psychiatry, Gitam Institute of Medical Sciences and Research, Visakhapatnam, Andhra Pradesh, India
4 Senior Resident, Department of Psychiatry, Gitam Institute of Medical Sciences and Research, Visakhapatnam, Andhra Pradesh, India
5 Assistant Professor, Department of Community Medicine, Maharaja Institute of Medical Sciences, Vizianagaram, Andhra Pradesh, India
|Date of Submission||27-Oct-2020|
|Date of Acceptance||21-Jan-2021|
|Date of Web Publication||20-Apr-2021|
Dr. Srinivas Singisetti
Department of Psychiatry, Gitam Institute of Medical Sciences and Research, Visakhapatnam - 530 045, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Introduction: Human behavior is very complex and driven by different motivations. At times, we find a deviant escape behavior in some situations, characterized by streaks of self-destruction or “suicidal behavior.” Defeat and entrapment have been hypothesized as central to this behavior.
Aim: We aimed to study the relationship between defeat, entrapment, suicidal ideation, and suicidal attempt.
Materials and Methods: This study was a cross-sectional study of fifty patients who attempted suicide and survived the attempt. When medically fit for psychological assessment, they were approached in a person in the hospital psychiatric ward. These patients were subjected to a detailed psychiatric interview, and any psychiatric illness in the patients was diagnosed using the Diagnostic and Statistical Manual of Mental Disorders V criteria. They were assessed on the defeat and entrapment scales by Gilbert and Allan. The Modified Scale for Suicidal Ideation by Ivan W. Miller was used to determine the presence or absence of suicidal ideation and severity of suicidal ideation.
Results: The presence of a current depressive disorder diagnosis and planning of attempt had a significant association with higher scores on internal entrapment, total entrapment, defeat, and suicidal ideation scales. The scores on defeat, internal entrapment, total entrapment, and suicidal ideation scales correlated positively and highly significantly.
Conclusion: Entrapment and defeat are identified as important in the pathogenesis of depression and self-harm. Arrested escape and flight appear as motivation for suicidal behavior.
Keywords: Defeat, depression, entrapment, suicidal ideation, suicide
|How to cite this article:|
Nukala S, Singisetti S, Vinnakota A, Chilikuri S, Garapati A, Sanapala V, Nambaru L. Defeat and entrapment in the pathogenesis of suicidal behavior. Arch Ment Health 2021;22:51-6
|How to cite this URL:|
Nukala S, Singisetti S, Vinnakota A, Chilikuri S, Garapati A, Sanapala V, Nambaru L. Defeat and entrapment in the pathogenesis of suicidal behavior. Arch Ment Health [serial online] 2021 [cited 2021 Nov 28];22:51-6. Available from: https://www.amhonline.org/text.asp?2021/22/1/51/314186
| Introduction|| |
Suicide is a significant public health problem across the globe. Around 800,000 people die from suicide every year. For every adult who dies by suicide, it is presumed that there may have been more than 20 others attempting suicide. India accounts for many suicides worldwide; suicide is the leading cause of death in young adults aged 15–39 in the country. Understanding the causes and correlates of suicide and the suicidal attempt is a complex task and remains the need of the hour.
In recent years, many psychological models have been developed better to understand the emergence of suicidal ideation and suicide attempts.,,,,, One such model is the integrated motivational–volitional (IMV) model of suicidal behavior [Figure 1],,, that builds upon Williams' work on defeat and entrapment, and describes the final common pathway to suicidal behavior. It hypothesizes that the experience of defeat/humiliation and entrapment are key drivers of suicidal ideation,, which leads to suicidal attempts/suicide. The IMV model also elucidates the factors that facilitate the transition from defeat/humiliation to entrapment, from entrapment to suicidal ideation, and from ideation to suicide attempt. In effect, suicidal behavior is an individual's attempt to end their pain or escape from painful life circumstances.
The concept of entrapment and its importance in the causation of mental health problems is not new. It emerged from the arrested flight literature as a model of depression that was subsequently applied to suicidal behavior.,, Entrapment is defined as the “blocking of a powerful motivation to escape from a stressful or threatening situation, due to a lack of escape possibilities or likelihood of rescue from others” and is derived from the concept of “arrested flight.” Such a state could be preceded by, triggered, and maintained by internal feelings and thoughts, known as internal entrapment, or external circumstances and events such as social situations, known as external entrapment. It can be viewed as a deficiency in problem-solving skills as a response to adverse circumstances. Animals experiencing social defeat are likely to engage in self-protective behaviors and strategies in the short term, including social withdrawal, decreased sleep and feeding, and hypervigilance. These are thought to prevent the further physical danger that could occur through further conflicts and signal a “no-threat” status. These submissive behaviors are protective and adaptive in the short term, as they aim to cutoff the animal from the dangerous environment. However, when these submissive behaviors prolong and fail to cease, it can lead to undesirable outcomes.
Given the evidence of the central role of defeat and entrapment in the suicidal process, the present study's goal was to evaluate and further establish the relationship between various patient factors, defeat, entrapment, and suicidal ideation with the suicidal attempt in an Indian setting.
Aim of the study
We aimed to study the relationship between defeat, entrapment, suicidal ideation, and suicidal attempt.
| Materials and Methods|| |
This study was a cross-sectional study carried out for 6 months, from June 2019 to December 2019 at the Department of Psychiatry, Gitam Institute of Medical Sciences and Research, Visakhapatnam. Fifty patients who attempted suicide and survived the attempt, when medically fit for psychological assessment, were approached in a person while admitted to the hospital's psychiatric ward. They were informed about the study aims and procedure, and those who gave consent were recruited for the study. Only patients who were 18 years old or more and capable of reading and communicating in the English language were included. Those suffering from any psychotic disorder or acute substance intoxication were excluded. Eligible patients were subjected to a detailed psychiatric interview, and any psychiatric illness in the patients was diagnosed using the Diagnostic and Statistical Manual of Mental Disorders V criteria. They were assessed on the defeat and entrapment scales by Gilbert and Allan (1998). The Modified Scale for Suicidal Ideation (MSSI) by Miller (1986) was used to look for suicidal ideation and severity of suicidal ideation in the patients. Permission from the Institutional Ethics committee was obtained before initiation of the study.
Description of tools used in the study
- A structured pro forma was prepared to record the patient's sociodemographic characteristics and clinical details and the suicide attempt. One of the clinical variables, i.e., whether the suicidal attempt was impulsive or planned, was arrived at by the assessing clinician's judgment based on the details of the suicidal attempt
- The entrapment scale, developed by Gilbert and Allan (1998), is further divided into an external and internal entrapment scale. External entrapment relates to the perception of things in the outside world that induces escape motivation. Internal entrapment relates to escape motivation triggered by internal feelings and thoughts. This 16-item entrapment scale asks participants to indicate on a five-point Likert scale the degree to which the items represent their thoughts and feelings. The response options are 0 = “not at all like me,” 1 = “a little bit like me,” 2 = “moderately like me,” 3 = “quite a bit like me,” and 4 = “extremely like me.” Gilbert and Allan (1998) reported high internal consistency levels for both student and depressed groups, with Cronbach's alphas, respectively, of 0.93 and 0.86 in internal entrapment, and 0.88 and 0.89 in external entrapment
- The defeat scale, developed by Gilbert and Allan (1998), is a 16-item scale asking participants to indicate on a five-point Likert scale ranging from 0 = never, 4 = always, how they felt defeated in the previous 7 days. This scale has high internal consistency with alpha coefficients of 0.94 for females and 0.93 for males, and a reliability of 0.94 for students and 0.93 for the depressed group
- The MSSI by Miller (1986) was used to assess the presence or absence of suicidal ideation and severity of suicidal ideation in the patients. The scale consists of 18 items. Each item consists of four statements that describe the severity of suicidal ideation representing on a four-point scale (0–3), referring to the previous 48 h. Participants are requested to choose a particular statement that is more applicable to them. The scale has cutoff instructions, wherein if items 1 and 2 are scored <2 and item 3 and 4 are 0, then it should not be further administered. Severity categories are based on total MSSI score: 0–8 for mild suicidal ideation, 9–20 for moderate suicidal ideation, and 21 and above for severe suicidal ideation. For serious suicidal ideation, one should have a score of 21 and above and should score >1 in items 7, 3, and 15.
| Results|| |
All statistical analysis was performed using the SPSS Trial version 16. Company based in the US. No year mentioned alongside as it is a trial version. and in MS Excel 2007. Qualitative variables were expressed as in frequencies and percentages. Quantitative variables were expressed as means and standard deviations. Chi-square test was used for examining the categorical data. Karl Pearson correlation coefficient was used to explore the relationship between quantitative variables. Student's t-test was used to compare the means between more two groups. For all statistical analyses, P < 0.05 was considered statistically significant.
[Table 1] indicates that depression has a highly significant association with the score on the internal entrapment scale, defeat scale, and suicidal ideation scale.
|Table 1: Comparison of current psychiatric diagnosis with scores of entrapment, defeat, and suicidal ideation scales|
Click here to view
[Table 2] indicates significantly higher scores in internal and total entrapment scales, defeat scale, and suicidal ideation scale, where the suicidal attempt was a planned one.
|Table 2: Comparison nature of attempt with scores of entrapment, defeat, and suicidal ideation scales|
Click here to view
[Table 3] and [Figure 2] depict a highly significant positive correlation between defeat and entrapment scales (r = 0.805, P = 0.000). There was also was a highly significant positive correlation between the defeat scale and suicide ideation scale scores (r = 0.745, P = 0.000).
|Table 3: Correlations between defeat, entrapment, and suicidal ideation scales|
Click here to view
|Figure 2: Correlation between internal entrapment and defeat scores, respectively, with suicidal ideatio|
Click here to view
| Discussion|| |
Self-preservation is an instinct. All life forms strive to protect themselves from various threats, within and without. Human beings, who are the highest on the evolutionary scale, are no exception to this. Human behavior is very complex and driven by different motivations, of which the selfish desire to stay alive is the most powerful one. In contrast to this natural behavior, at times, we find a deviant behavior in some situations, characterized by streaks of self-destruction or “suicidal behavior.” The concepts of defeat and entrapment have been hypothesized as central to this behavior, and we discuss here further the findings from our study in relation to these.
Sociodemographic and clinical distribution of patients
In our study of 50 patients [Table 4], most of the patients with suicide attempts were females, from an urban background, with education above matriculation, unemployed, married, and from the Hindu religion. Fifty-eight percent of the suicide attempts in the study were planned in nature. The commonest method was poisoning with organophosphorus agents or by drug overdose, which probably reflects the easy availability of these substances at home and local markets. In the present study, past suicidal attempts were noted in 38% of the sample, which often is a risk factor in predicting future attempts. A diagnosis of current depressive disorder was present in about half of the patients, in keeping with the well-known association between suicidal attempts and depression.
|Table 4: Demographic and clinical variables of patients with suicide attempt (n=50)|
Click here to view
The relation between clinical variables and defeat, entrapment, and suicidal ideation scales
The presence of a current depressive disorder diagnosis and planning of attempt had a significant association with higher scores on internal entrapment, total entrapment, defeat, and suicidal ideation scales. Interestingly, both the variables did not significantly associate with external entrapment scores, suggesting the importance of negative ideation and feelings rather than external events itself in the pathway of suicidal attempt. On the same lines, statements such as “I feel there is no fight left in me” and “I feel trapped in myself” from defeat and entrapment scales, respectively, were ones that were most frequently scored high by the patients. Chronic defeat and entrapment, potentially leading to depression over time, makes an individual consider suicide as a solution to get out of suffering in life.
The concepts of defeat and entrapment were proposed initially within the evolutionary theories of depression in animal studies, which showed that socially defeated animals briefly engaged in self-protective strategies such as social withdrawal. Involuntary defeat syndrome is described in animals where such adaptive behaviors occur following a defeat in a dangerous situation to protect the animal from further harm. As any motivation to escape from the aversive situation is blocked, and animals cannot physically escape, they engage in a defensive strategy known as “arrested flight” and display submissive behaviors to “cutoff” from the environment. These behaviors that mirror the psychopathological responses in humans strengthen the concepts of defeat and entrapment in humans. In our study, the scores on defeat, internal entrapment, total entrapment, and suicidal ideation scales correlated positively and highly significantly.
| Conclusion|| |
Defeat and entrapment are proposed hypothesis in the pathogenesis of self-harm and suicide. This study shows a significant correlation in the levels of defeat, internal entrapment, and suicidal ideation experienced in patients presenting with suicidal attempts. Such scores also had a significant association with factors such as current depressive illness and the planning of an attempt. These findings would strengthen that model that arrested escape and feelings of defeat and entrapment are significant motivators for suicidal ideation and subsequent behavior in humans.
Defeat and entrapment having a significant association with suicidal attempts could potentially serve as predictors for suicidal attempts and suicide. Therefore, the need to be routinely incorporated into risk assessments in mental health settings. With a potential role in the pathogenesis and etiology of suicide, these experiences and beliefs serve as a target for intervention in a psychotherapeutic setting. Prospective studies on entrapment and suicidal behavior should be prioritized to establish the predictive and causative role and look beyond association alone. Research examining associated clinical factors, and whether entrapment is culturally sensitive, gender sensitive, or age sensitive, is also recommended.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
India State-level Disease Burden Initiative Suicide Collaborators. Gender differentials and state variations in suicide deaths in India: The global burden of disease study 1990-2016. Lancet 2018;3:E478-89.
Klonsky ED, May AM. The three-step theory (3ST): A new theory of suicide rooted in the “ideation-to-action” framework. Int J Cogn Ther 2015;8:114-29.
O'Connor RC. Towards an integrated motivational-volitional model of suicidal behavior. In: O'Connor RC, Platt S, Gordon J, editors. International Handbook of Suicide Prevention: Research, Policy and Practice. Chichester, UK: Wiley; 2011. p. 181-98.
Van Orden KA, Witte TK, Cukrowicz KC, Braithwaite SR, Selby EA, Joiner TE Jr. The interpersonal theory of suicide. Psychol Rev 2010;117:575-600.
O'Connor RC, Nock MK. The psychology of suicidal behaviour. Lancet Psychiatry 2014;1:73-85.
Johnson J, Gooding PA, Wood AM, Tarrier N. Resilience as positive coping appraisals: Testing the schematic appraisals model of suicide (SAMS). Behav Res Ther 2010;48:179-86.
Williams JM. Suicide and Attempted Suicide: Understanding the Cry of Pain. London: Penguin; 2001.
O'Connor RC, Cleare S, Eschle S, Wetherall K, Kirtley OJ. The integrated motivational-volitional model of suicidal behavior: An update. In: O'Connor RC, Pirkis J, editors. The International Handbook of Suicide Prevention. Chichester: Wiley Blackwell; 2016. p. 220-40.
Klonsky ED, May AM. Differentiating suicide attempters from suicide ideators: A critical frontier for suicidology research. Suicide Life Threat Behav 2014;44:1-5.
O'Connor RC. The integrated motivational-volitional model of suicidal behavior. Crisis 2011;32:295-8.
Gilbert P, Allan S. The role of defeat and entrapment (arrested flight) in depression: An exploration of an evolutionary view. Psychol Med 1998;28:585-98.
Dixon AK. Ethological strategies for defence in animals and humans: Their role in some psychiatric disorders. Br J Med Psychol 1998;71:417-45.
Dixon AK, Fisch HU, Huber C, Walser A. Ethological studies in animals and man, their use in psychiatry. Pharmacopsychiatry 1989;22:44-50.
Taylor PJ, Gooding P, Wood AM, Tarrier N. The role of defeat and entrapment in depression, anxiety, and suicide. Psychol Bull 2011;137:391-420.
Williams JM, Pollock LR. Psychological aspects of the suicidal process. In: Van Heeringen K, editor. Understanding Suicidal Behaviour: The Suicidal Process Approach to Research, Treatment and Prevention. Chichester: John Wiley and Sons; 2001. p. 76-93.
Sloman L, Gilbert P, Hasey G. Evolved mechanisms in depression: The role and interaction of attachment and social rank in depression. J Affect Disord 2003;74:107-21.
Price J, Sloman L. Depression as yielding behavior: An animal model based on Schjelderup-Ebbe's pecking order. Ethol Sociobiol 1987;8:85-98.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th
ed. Arlington, VA: American Psychiatric Association; 2013.
Miller IW, Norman WH, Bishop SB, Dow MG. The modified scale for suicidal ideation: Reliability and validity. J Consult Clin Psychol 1986;54:724-5.
Price J, Sloman L, Gardner R, Gilbert P, Rohde P. The social competition hypothesis of depression. Br J Psychiatry 1994;164:309-15.
Sloman L. How the involuntary defeat strategy relates to depression. In: Sloman L, Gilbert P, editors. Subordination and Defeat: An Evolutionary Approach to Mood Disorders and their Therapy. Mahwah, NJ: Lawrence Erlbaum Associates Publishers; 2000. p. 47-67.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]