1 of 8Clinical Psychology & Psychotherapy, 2024; 31:e70000 https://doi.org/10.1002/cpp.70000 Clinical Psychology & Psychotherapy RESEARCH ARTICLE OPEN ACCESS Relationship Between the Feeling of Emptiness and Suicide Reattempt: Conclusions From Cross-Sectional and Longitudinal Analyses Andres Pemau1,2,3   | Carolina Marin-Martin1  | Alejandro de la Torre-Luque2,4,5  | Wala Ayad-Ahmed2,3,6   | Jose Manuel Lopez-Villatoro2,3,6  | Veronica Fernandez-Rodrigues2,3,6  | Pablo Mola3   | Jose Luis Carrasco2,3,4,5,6  | Marina Diaz-Marsa2,3,4,5,6 1Departamento de Personalidad, Evaluación y Psicología Clínica, Universidad Complutense de Madrid, Madrid, Spain  |  2Grupo de Investigación en Epidemiología Psiquiátrica y Salud Mental (EPISAM), Universidad Complutense de Madrid, Madrid, Spain  |  3Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain  |  4Centro de Investigación Biomédica en Red Salud Mental (CIBERSAM), Madrid, Spain  |  5Departamento de Medicina Legal, Psiquiatría y Patología, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain  |  6Hospital Clínico San Carlos, Madrid, Spain Correspondence: Alejandro de la Torre-Luque (af.delatorre@ucm.es) Received: 6 August 2024  |  Revised: 27 September 2024  |  Accepted: 30 September 2024 Funding: This study was supported by the Instituto de Salud Carlos III-FIS research grants (PI19/01256, PI20/01471, PI20/00229, PI23/00707 and PI23/00085), funded by the ISCIII and cofunded by the European Regional Development Fund (ERDF). It was also supported by a FPU grant (FPU20/01651) from the Spanish Ministry of Universities and a Universidad Complutense de Madrid predoctoral contract for research staff in training (CT82/20-CT83/20). Keywords: feeling of emptiness | suicide | suicide reattempt | survival analysis ABSTRACT Introduction: The feeling of emptiness is a complex subjective experience considered relevant in the suicidal process, acting as a risk factor for suicide ideation, attempts and even reattempts. However, empirical studies are still scarce. Objectives: This study has three objectives: to compare emptiness levels in healthy people and those with suicide attempts; to compare the emptiness level between people with a single suicide attempt and multiple suicide attempts at baseline; and to study emptiness as a risk factor for the appearance of new suicidal attempts after an index one. Methodology: In the study, 382 healthy controls and 58 participants with a recent suicide attempt (in the past 15 days) partici- pated. All completed the feeling of emptiness scale (FES). Information was also collected on sociodemographic characteristics and history of suicide attempts. First, the control sample scores were compared with those of the clinical sample. Later, the single attempt and reattempt groups (any amount greater than one attempt at baseline) were compared. Finally, the clinical sample was followed for 1 year and 3 months (through clinical records). Survival analysis was performed. Results: The clinical group obtained higher scores across the FES subscales, even when controlling for other relevant variables (p < 0.01). When comparing people with one versus several attempts, differences were also observed in all subscales except one, the reattempt group getting higher scores (p < 0.05). Regarding the survival analysis, the feeling of emptiness was significantly associ- ated with the risk of reattempt (HR = 1.04; p < 0.05). All people who reattempted during follow-up belonged to the reattempt group at baseline. Conclusions: People who have attempted suicide present higher emptiness scores. Furthermore, emptiness appears to signif- icantly predict the occurrence of new attempts at follow-up. The feeling of emptiness may be associated with the lack of vital meaning and disconnection from others, fundamental aspects of the ideation-to-action suicide models. Including emptiness in suicide assessments could increase clinicians' predictive ability. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made. © 2024 The Author(s). Clinical Psychology & Psychotherapy published by John Wiley & Sons Ltd. https://doi.org/10.1002/cpp.70000 https://doi.org/10.1002/cpp.70000 https://orcid.org/0000-0002-5835-507X mailto: https://orcid.org/0000-0002-0786-0076 https://orcid.org/0009-0002-9232-8662 mailto:af.delatorre@ucm.es http://creativecommons.org/licenses/by-nc-nd/4.0/ 2 of 8 Clinical Psychology & Psychotherapy, 2024 1   |   Introduction Suicide is one of the leading external causes of death world- wide. The World Health Organization (WHO) points out that more than 700,000 people may die annually due to suicide (WHO 2023). However, the suicidal phenomenon is not limited to deaths by suicide. Other forms of suicidal behaviour (plan- ning, attempts, reattempts, …) are of great interest due to their impact on health and functioning status (Benson et  al.  2021; Bommersbach, Rosenheck, and Rhee 2023). The most recent models consider suicide from an ideation-to- action perspective. These models move away from the traditional unitary conception of suicidal behaviour (e.g., Beck et al. 1985; Linehan  1993). They propose mechanisms to first explain the emergence of suicidal ideation and then the processes leading to suicidal behaviours. Each mechanism presents its own risk fac- tors (Joiner 2005; Klonsky, Saffer, and Bryan 2018; Klonsky and May  2015; O'Connor  2011). Numerous risk factors associated with suicidal behaviours have been studied: presence of psycho- pathology, family history, substance use or adverse life events, just to name a few (Turecki and Brent 2016). One of the risk fac- tors that has recently gained interest is the feeling of emptiness (Blasco-fontecilla et al. 2013; Herron et al. 2024). The feeling of emptiness is a complex subjective experience relevant in different psychiatric diagnoses. It plays a key role in borderline personality disorder, being one of its diagnostic criteria (American Psychiatric Association [APA]  2022). Different studies focused on the subjective feeling of emptiness point out its relationship with the lack of vital meaning, unfulfillment, disconnection from oneself and others and inner void (Herron and Sani 2022; Miller, Townsend, and Grenyer 2021). This indicates that emptiness may be a multifaceted and complex human experience. In summary, it represents a clinical characteristic of great interest potentially involved in the pathophysiology of varying mental conditions but poorly defined (D'Agostino et al. 2020; Miller et al. 2020). The feeling of emptiness has been associated with a wide range of suicide behaviour forms: ideation, attempts and, to a lesser extent, reattempts (Blasco-Fontecilla et  al.  2015; Fulham, Forsythe, and Fitzpatrick  2023; Grilo and Udo  2021; Herron et  al.  2024; Klonsky  2008; Liu et  al.  2016; López-Villatoro et  al.  2022; Otsuka and Anamizu  2019). Some studies high- light that this subjective experience may play a pivotal role in suicide even when considering other variables (Blasco-fontecilla et al. 2013; Blasco-Fontecilla et al. 2012). Although the nature of the relationship is unclear, various mecha- nisms have been proposed. Some authors consider that the feeling of emptiness is related to a lack of connection with others (Fulham, Forsythe, and Fitzpatrick 2023; Yen et al. 2021). In turn, Ideation- to-action models propose thwarted belonging and the lack of social connectedness as two nuclear points in the suicidal ideation gen- esis (Joiner 2005; Klonsky and May 2015; O'Connor 2011). That is, disconnection would be the link between suicidal ideation and emptiness. Also, O'Connor (2011) raises the relevance of the ab- sence of goals in the development of suicidal ideation. This aspect is also negatively affected by emptiness (Yen et al. 2021). Other works propose that people with greater feelings of emp- tiness would use self-harming and suicidal behaviours to overcome those feelings or, as it has been labelled by some authors, for ‘feeling generation’ (Blasco-Fontecilla et  al.  2015; Klonsky  2007). Finally, the feeling of emptiness has been as- sociated with other variables close to suicidal behaviour, such as dysphoria or loneliness (D'Agostino et al. 2020). In brief, the mechanism joining suicide and emptiness has not yet been un- ravelled, with several possible explanations. Studies indicate that people with a wide range of mental health diagnoses can experience emptiness (D'Agostino et  al.  2020; Hudson et  al.  2024; Klonsky  2008). Even healthy population acknowledge having felt emptiness at some point (Herron and Sani 2022; Martin and Levy 2022). However, most studies have focused on the population with borderline personality disor- der (Fulham, Forsythe, and Fitzpatrick  2023; López-Villatoro et al. 2022; Yen et al. 2021). The use of validated and complex emptiness measurements is more the exception than the rule. In addition, its association with suicide reattempt has been largely ignored, even though some papers suggest a relationship between major repeaters and emptiness (five or more attempts lifetime; Blasco-Fontecilla et al. 2015). The present study has three objectives: first, to compare the feel- ing of emptiness in people with a suicide attempt versus healthy controls; second, to compare the feeling of emptiness in people with one attempt and multiple attempts at baseline; and finally, to study the relationship between the feeling of emptiness measured at baseline and the appearance of new suicide attempts in the next 15 months. We hypothesize that people who have attempted suicide will pres- ent higher levels of emptiness than the control sample. Also, those with more than one attempt will score higher. Finally, the feeling of emptiness at baseline will be a risk factor for reattempt during the follow-up. 2   |   Methods 2.1   |   Participants For this study, there were 382 controls, and 58 participants ad- mitted a hospital emergency unit due to a suicide attempt (within the last 15 days). Within the clinical sample, 21 participants had a single attempt, and 37 had two or more (at baseline). Summary • People who have attempted suicide have higher feel- ings of emptiness than the general population. • People who have several lifetime suicide attempts pres- ent higher emptiness scores than people after a first attempt. • The emptiness score after an index attempt could help predict the occurrence of new suicide attempts in the future. • Including emptiness in suicide assessments could in- crease clinicians' predictive ability. 10990879, 2024, 5, D ow nloaded from https://onlinelibrary.w iley.com /doi/10.1002/cpp.70000 by A ndrés Pem au - U niversity O f G lasgow , W iley O nline L ibrary on [23/10/2024]. See the T erm s and C onditions (https://onlinelibrary.w iley.com /term s-and-conditions) on W iley O nline L ibrary for rules of use; O A articles are governed by the applicable C reative C om m ons L icense https://onlinelibrary.wiley.com/action/rightsLink?doi=10.1002%2Fcpp.70000&mode= 3 of 8 Control group was recruited using advertisements through dif- ferent media (social networks, email, etc.), as part of a wider pro- tocol of suicide risk screening in Madrid (Spain). Participants in this group could not present previous suicide attempts or history of mental disorders. Healthy controls were included to present a baseline with which to compare people with suicide at- tempts. The clinical sample was recruited among people who at- tended the emergency room at the San Carlos Clinical Hospital (Madrid, Spain) for a suicide attempt. People with cognitive or neuropsychological deficits that prevented understanding of the instructions were excluded from the study. All participants in both groups had to be 18 years or older. All participants received information about the study and signed the corresponding informed consent. The corresponding ethics committees approved the study. 2.2   |   Instruments Participants completed a sociodemographic interview contain- ing data on educational level, employment status, nationality and age. Afterwards, they indicated whether they had made any suicide attempts throughout their lives. The difference between suicide attempts and self-harm was specifically emphasized (at- tempts should have been carried out with at least some wish to die). If the participant presented suicide attempts, the suicide history was extracted from the application of the Columbia Suicide Rating Scale (C-SSRS; Posner et al. 2011; Spanish ver- sion by Al-Halabí et al. 2016). Chronic feeling of emptiness was measured with the feeling of emptiness scale (FES; Palomares et al. 2020). This instrument was developed for Spanish sample. The scale consists of 33 items answered on a 5-point Likert scale (between 0, never, and 4, always). It has a Cronbach's alpha of 0.97 and adequate in- dicators of convergent validity. The test allows the calculation of a global emptiness score as well as a score on five subscales. Although the validation did not name the subscales, they could be summarized as follows: (1) emotional disconnection; (2) need to be valued; (3) loss of vital meaning; (4) loneliness; and (5) lack of self-direction. The clinical records were consulted to check if there were reattempts during follow-up. 2.3   |   Data Analysis 2.3.1   |   Cross Sectional The sociodemographic variables were compared between the control and clinical groups. For this, χ2 and Student's t tests were used (for categorical and continuous variables, respectively). Subsequently, the analysis of covariance test (ANCOVA) was used to study the differences in emptiness between the groups, controlling for relevant sociodemographic variables. Finally, to compare the level of emptiness between the single attempt group and the reattempt group, Student's t tests were used. The η2 partial was used as a measure of effect size in the ANCOVA analyses. The Hedges' g was used when working with Student's t test. Finally, φ coefficient was used for χ2 analysis. An η2 partial of 0.01, 0.06 and ≥0.14 can be considered small, medium and large, respectively. Regarding Hedges' g, 0.2 indicates a small effect size, 0.5 moderate and around 0.8 large (Cohen  2013). The φ values are interpreted as follows: >0.05 weak effect, >0.10 medium effect and >0.15 strong effect (Akoglu 2018). 2.3.2   |   Survival Analysis Once cross-sectional analysis was completed, survival analy- sis was used. For this, only the clinical sample was considered. First, The Kaplan–Meier curves were used to estimate the risk of reattempting within the sample. Then, unadjusted Cox re- gression was used to study the association between the feeling of emptiness at baseline (total score) and the Hazard of attempt repetition. Finally, penalized Cox regression was performed to study the association between the feeling of emptiness and the Hazard of repetition, adjusted for the presence or absence of attempts prior to the index one (the index attempt is the one that occurred in the previous 15 days). The follow-up length was 15 months (456 days). The average number of days under fol- low-up was 419 (range: 92–456). Analyses were performed using R software Version 4.2.2 (pack- ages survival, bshazard and coxphf) and SPSS version 28.0.1.1. 3   |   Results Descriptive data on the participants are presented in Table  1. Regarding the quantitative variables, the mean age of the con- trol sample was 21.63 (SD = 4.50), and that of the clinical group was 35.52 (SD = 14.68), showing a statistically significant differ- ence (p < 0.01). The average number of suicide attempts in the clinical group was 2.97 (SD = 3.37). In terms of the categorical variables, the groups differed in sex at birth, country of origin occupation and educational level (p < 0.01 in all cases except for country, p < 0.05). Given the differences in sociodemographic variables that could affect our study, a linear regression (block introduction, forward entry method) was performed, with the dependent variable being the total emptiness score. In the first block, all the socio- demographic variables were introduced. Then, the group was considered (clinical or control). Results can be seen in Table S1. The only significant variables in the model were group, age and occupation (p < 0.01). Taking this into account, ANCOVA tests were carried out to ob- serve the differences between the groups in the scales of the FES and the total score, controlling for age and occupation. These comparisons are available in Figure  1. As can be seen, significant differences are found in all subscales, even when controlling the effect of covariables: (1) emotional disconnec- tion (F = 286.72; p < 0.01; η2 partial = 0.40); (2) need to be valued (F = 160.54; p < 0.01; η2 partial = 0.27); (3) loss of vital meaning (F = 157.23; p < 0.01; η2 partial = 0.27); (4) loneliness (F = 106.15; p < 0.01; η2 partial = 0.20); and (5) lack of self-direction (F = 62.16; p < 0.01; η2 partial = 0.13), as well as in the total score (F = 230.26; 10990879, 2024, 5, D ow nloaded from https://onlinelibrary.w iley.com /doi/10.1002/cpp.70000 by A ndrés Pem au - U niversity O f G lasgow , W iley O nline L ibrary on [23/10/2024]. See the T erm s and C onditions (https://onlinelibrary.w iley.com /term s-and-conditions) on W iley O nline L ibrary for rules of use; O A articles are governed by the applicable C reative C om m ons L icense https://onlinelibrary.wiley.com/action/rightsLink?doi=10.1002%2Fcpp.70000&mode= 4 of 8 Clinical Psychology & Psychotherapy, 2024 p < 0.01; η2 partial = 0.35). In all cases, the clinical sample pre- sented higher scores than the control sample. Now, comparisons between the single attempt group and the reattempt group are presented. Of the 58 participants in the sample, 21 had a single attempt, and 37 had two or more. The mean age of the group with one attempt was 38.86 (SD = 17.60), and that of the reattempt group was 33.62 (SD = 12.61). The reat- tempt group had made an average of 4.08 (SD = 3.80) attempts. χ2 tests were carried out to check if there were differences in the TABLE 1    |    Comparisons of sociodemographic data between clinical sample and controls. Variable Control (n = 382) Clinical (n = 58) t/χ2 Effect sizes (g/φ) Age 21.63 (4.50) 35.52 (14.68) 7.15** 2.05 Attempts — 2.97 (3.37) — Gender Male 184 (48.20%) 6 (10.34%) 29.36** 0.26 Female 198 (51.70%) 52 (89.66%) Studies Primary/Secondary school 116 (30.40%) 38 (69.60%) 27.35** −0.25 University 266 (65.50%) 20 (34.48%) Country Spain 320 (83.80%) 41 (70.69%) 5.85* 0.12 Other 62 (16.20%) 17 (29.30%) Occupation Unemployed 12 (3.10%) 19 (32.80%) 67.45** −0.39 Employed 370 (96.9%) 39 (67.20%) Note: Scores are presented as mean (standard deviation) for continuous variables and count (percentage) for categorical variables. In comparisons between continuous variables, Hedges' g was used as a measure of effect size. In the categorical ones, the φ coefficient was used. When talking about occupation, employed also includes students. *Statistically significant differences at p < 0.05. **Statistically significant differences at p < 0.01. FIGURE 1    |    Comparisons of FES scores between clinical sample and controls. Note: Error bars 95% CI (*) statistically significant differences at p < 0.05 and (**) statistically significant differences at p < 0.01. 10990879, 2024, 5, D ow nloaded from https://onlinelibrary.w iley.com /doi/10.1002/cpp.70000 by A ndrés Pem au - U niversity O f G lasgow , W iley O nline L ibrary on [23/10/2024]. See the T erm s and C onditions (https://onlinelibrary.w iley.com /term s-and-conditions) on W iley O nline L ibrary for rules of use; O A articles are governed by the applicable C reative C om m ons L icense https://onlinelibrary.wiley.com/action/rightsLink?doi=10.1002%2Fcpp.70000&mode= 5 of 8 demographic variables (gender, work, studies and country of or- igin) between both groups. Neither test was significant. Table S2 includes information on these comparisons. Figure 2 shows the results of the comparisons between groups in the different FES scores. Differences were observed in the total emptiness score (t = −3.27; p < 0.01; Hedges' g = −0.88), as well as in all its subscales except 5 (lack of self-direction): (1) emo- tional disconnection (t = −3.06; p < 0.01; Hedges' g = −0.83); (2) need to be valued (t = −2.76; p < 0.01; Hedges' g = −0.74); (3) loss of vital meaning (t = −3.68; p < 0.01; Hedges' g = −0.99); and (4) loneliness (t = −2.53; p < 0.05; Hedges' g = −0.68). The feeling of emptiness was always higher in people who have made more than one attempt compared to those who have only attempted suicide on one occasion. With respect to survival analysis, Figure 3 shows the survival function as well as the Hazard function for suicide reattempt. Eleven people made a suicide reattempt (19%) during fol- low-up. Of these 11, 82% were women, and the average age was 30.36 years. The majority were Spanish (82%), with university education (54.5%) and employed (63.6%). For all the participants that reattempted suicide at follow-up, the index attempt was not the first lifetime attempt. One person died by suicide during follow-up. First, the unadjusted Cox regression considering only the total emptiness score is presented: hazard ratio (HR) = 1.05; 95% CI = 1.01, 1.09; p < 0.01. After adjusting for group at baseline (reattempt or first attempt group) using penalized cox regression, emptiness total score was still significantly associated with suicide reattempt (adjusted hazard ratio [AdHR] = 1.04; 95% CI = 1.01, 1.08; p < 0.05). For every point that the emptiness score increased, individuals presented 4% greater hazard of suicide reattempt. Regarding the effect of presenting several attempts at baseline, the effect was also significant (AdHR = 8.94; 95% CI = 1.13, 1155.26; p < 0.05). This confidence interval is highly unstable. This is due to the total separation derived from the fact that all people who re- attempted suicide during follow-up already belonged to the reattempt group at baseline. To avoid separation, the survival analysis of only the reattempt group at baseline was also con- sidered. The feeling of emptiness continued to be significant even then (HR = 1.04; 95% CI = 1.01, 1.08; p < 0.05). 4   |   Discussion This study started with three objectives: to observe whether people with suicide attempts had higher emptiness scores than the general population; to check if people with several attempts presented higher emptiness levels when compared to people with only one attempt; and finally, to study the pre- dictive potential of the feeling of emptiness in the face of new suicide attempts. Our results point out that people who have attempted suicide have significantly higher levels of emptiness than the control sample. This was the case both for the total score on the FES and for all its subscales even when controlling for other rele- vant variables (e.g., age and occupation). Previous work already pointed out the association between emptiness and suicide at- tempts, although usually in samples only conformed of patients with borderline personality disorder or that used more limited measures of emptiness (Blasco-Fontecilla et al. 2012; Fulham, Forsythe, and Fitzpatrick 2023; López-Villatoro et al. 2022; Yen et al. 2021). Although the scores are significantly lower, the con- trol sample also disclosed feeling empty, in line with previous studies (Martin and Levy 2022). Also, people with more than one attempt at baseline scored higher on the global FES as well as on the different subscales ex- cept for Subscale 5 (lack of self-direction). Specifically, Subscale 5 includes only two items. Its small size could partially explain why no differences were found, as there is less variability. The work by López-Villatoro et al.  (2022), focused on suicidal FIGURE 2    |    Comparisons of FES scores between the single attempt group and the reattempt group. Note: Error bars 95% CI (*) statistically significant differences at p < 0.05 and (**) statistically significant differences at p < 0.01. 10990879, 2024, 5, D ow nloaded from https://onlinelibrary.w iley.com /doi/10.1002/cpp.70000 by A ndrés Pem au - U niversity O f G lasgow , W iley O nline L ibrary on [23/10/2024]. See the T erm s and C onditions (https://onlinelibrary.w iley.com /term s-and-conditions) on W iley O nline L ibrary for rules of use; O A articles are governed by the applicable C reative C om m ons L icense https://onlinelibrary.wiley.com/action/rightsLink?doi=10.1002%2Fcpp.70000&mode= 6 of 8 Clinical Psychology & Psychotherapy, 2024 behaviour in emotionally unstable disorders, found that not all subscales were equally associated with suicide attempt. Specifically, Factors 1 (emotional disconnection) and 4 (lone- liness) were the most relevant. Although in our case we found more associated factors, it is partially consistent with those find- ings. This could reinforce the complex and multicomponent na- ture of the feeling of emptiness. Although this is a less explored area, some previous works pre- sented the possible association of emptiness with major repeat- ers (Blasco-Fontecilla et al. 2015, 2016). In our case, we find an association between reattempt and emptiness even without lim- iting to major repeaters. Focusing now on the survival analysis, both the presence of attempts prior to the index one and the total emptiness score predicted the appearance of attempts during follow-up. The first finding is consistent with previous work (Pemau et al. 2024). Previous attempts are related to the acquired capa- bility for suicide, a core concept in the ideation to action models (Joiner 2005; O'Connor 2011). The proportion of reattempts in the sample was also consistent with previous work (de la Torre- Luque et  al.  2023). However, the predictive capacity of empti- ness is novel. It is necessary to explain the mechanism connecting suicide attempt and emptiness. Previous works (Miller, Townsend, and Grenyer  2021; Yen et  al.  2021) hypothesized about the possible relationship between emptiness and core concepts of the ideation-action models such as thwarted belonging- ness or connectedness (Joiner  2005; Klonsky and May  2015; O'Connor  2011; van Orden et  al.  2010). In fact, emptiness involves a strong disconnection from both one and the oth- ers. The feeling of lack of direction and belongingness could be affecting connectedness and goal-oriented behaviour, thus increasing the risk of suicide attempt. Other studies suggest that emptiness has a strong association with hope- lessness, particularly affecting suicidal ideation (D'Agostino et  al.  2020; Klonsky  2008). On the other hand, emptiness is also a widely reported feeling after making a suicide attempt (Blasco-fontecilla et al. 2013). Regarding the association between the number of attempts and emptiness, the works are much scarcer. Blasco-Fontecilla et al. (2015, 2016) raise the need to ‘feel something’ as a possi- ble fit between the major repeaters and the feeling of emptiness. That is, people who feel emptier tend to make more attempts for ‘feeling generation’. In summary, the relationship between suicidal behaviour and feeling of emptiness could be bidirectional. Having survived an attempt could increase the feeling of emptiness. In turn, the feeling of emptiness would act as a risk factor for new attempts. We now present the limitations of the study. First, there were relevant differences in the sociodemographic variables between the control and clinical groups. Through ANCOVAs, this effect should be controlled. The diagnosis was not considered. Although this could be con- sidered a limitation, the aim was to study the feeling of empti- ness as a transdiagnostic phenomenon, in this case the specific diagnosis being secondary. Previous works already raise the transdiagnostic value of the feeling of emptiness (Herron and Sani 2022; Konjusha et al. 2021). There are other relevant vari- ables not included in this study, such as the duration of the symptoms or the temporal distance between suicide attempts, which could affect the results. There is a numerical imbalance between the number of healthy controls and people with suicide attempts. This difference could influence some of the results found. Also, the sample considered for the survival analysis is relatively limited; it would be advis- able to try to replicate the results with access to larger samples. Linked to this, the fact that all patients who presented a reattempt belonged to the reattempt group at baseline resulted in wide con- fidence intervals when using penalized Cox regression. Even so, the relevance of the feeling of emptiness continued to appear even when considering only the reattempt group in analysis. Finally, it is necessary to consider that diagnoses, as well as other complex human behaviours, are rarely explained in a univariate way. Currently, special attention is being given to this causal FIGURE 3    |    Survival and hazard functions for time to reattempt. Note: In the left graph, the solid line represents the survival probability. Each descent of the solid line represents a reattempt. The dashed lines represent the confidence interval. (|) represents cases censored before the end of follow-up. 10990879, 2024, 5, D ow nloaded from https://onlinelibrary.w iley.com /doi/10.1002/cpp.70000 by A ndrés Pem au - U niversity O f G lasgow , W iley O nline L ibrary on [23/10/2024]. See the T erm s and C onditions (https://onlinelibrary.w iley.com /term s-and-conditions) on W iley O nline L ibrary for rules of use; O A articles are governed by the applicable C reative C om m ons L icense https://onlinelibrary.wiley.com/action/rightsLink?doi=10.1002%2Fcpp.70000&mode= 7 of 8 complexity through approaches such as the symptom networks, rather than traditional diagnostic views (Borsboom  2017). Future work should introduce the feeling of emptiness in inter- action with other variables to test its true relevance. To our knowledge, we are the first work that longitudinally studies the relationship between suicide reattempt and the feel- ing of emptiness. This, together with studies that have found an association between emptiness and other forms of suicidal behaviour, present emptiness as a relevant variable for suicid- ality. In fact, it could predict the appearance of new attempts after an index one. It is necessary to focus more studies on this relationship, considering it together with other variables. The characteristics of the feeling of emptiness in the general popula- tion also deserve more attention in future studies. Including the feeling of emptiness as part of the evaluations and interventions in patients with suicidal behaviour could be useful to avoid the appearance of new attempts. Acknowledgements This study was supported by the Instituto de Salud Carlos III-FIS re- search grants (PI19/01256, PI20/01471, PI20/00229, PI23/00707, PI23/00085), funded by the ISCIII and cofunded by the European Regional Development Fund (ERDF), “A way to make Europe”. It was also supported by a FPU grant (FPU20/01651) from the Spanish Ministry of Universities and a Universidad Complutense de Madrid Predoctoral contract for research staff in training (CT82/20-CT83/20). Ethics Statement All participants received information about the study and signed the corresponding informed consent. The corresponding ethics committees approved the study. Conflicts of Interest The authors declare no conflicts of interest. Data Availability Statement The data that support the findings of this study are available from the corresponding author upon reasonable request. References Akoglu, H. 2018. “User's Guide to Correlation Coefficients.” Turkish Journal of Emergency Medicine 18: 91–93. https://​doi.​org/​10.​1016/j.​tjem.​ 2018.​08.​001. Al-Halabí, S., P. A. Sáiz, P. Burón, et al. 2016. “Validation of a Spanish Version of the Columbia-Suicide Severity Rating Scale (C-SSRS).” Revista de Psiquiatría y Salud Mental (English Edition) 9: 134–142. https://​doi.​org/​10.​1016/j.​rpsmen.​2016.​06.​004. American Psychiatric Association. 2022. Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) (5th ed., Text Rev.). Washington, DC: American Psychiatric Association. Beck, A. T., R. A. Steer, M. Kovacs, and B. Garrison. 1985. “Hopelessness and Eventual Suicide: A 10-Year Prospective Study of Patients Hospitalized With Suicidal Ideation.” American Journal of Psychiatry 142: 559–563. https://​doi.​org/​10.​1176/​ajp.​142.5.​559. Benson, C., D. Singer, C. M. Carpinella, M. Shawi, and L. Alphs. 2021. “The Health-Related Quality of Life, Work Productivity, Healthcare Resource Utilization, and Economic Burden Associated With Levels of Suicidal Ideation Among Patients Self-Reporting Moderately Severe or Severe Major Depressive Disorder in a National Survey.” Neuropsychiatric Disease and Treatment 17: 111–123. https://​doi.​org/​10.​2147/​NDT.​S229530. Blasco-fontecilla, H., V. D. L. Ba, D. Delgado-gomez, L. Giner, S. Guillaume, and P. Courtet. 2013. “Emptiness and Suicidal Behavior: An Exploratory Review.” Suicidology Online 4: 21–32. Blasco-Fontecilla, H., E. Baca-García, P. Courtet, R. García Nieto, and J. de Leon. 2015. “Horror Vacui: Emptiness Might Distinguish Between Major Suicide Repeaters and Nonmajor Suicide Repeaters: A Pilot Study.” Psychotherapy and Psychosomatics 84: 117–119. https://​doi.​org/​10.​1159/​ 00036​9937. Blasco-Fontecilla, H., D. Delgado-Gomez, D. Ruiz-Hernandez, D. Aguado, E. Baca-Garcia, and J. Lopez-Castroman. 2012. “Combining Scales to Assess Suicide Risk.” Journal of Psychiatric Research 46: 1272– 1277. https://​doi.​org/​10.​1016/j.​jpsyc​hires.​2012.​06.​013. Blasco-Fontecilla, H., R. Fernández-Fernández, L. Colino, L. Fajardo, R. Perteguer-Barrio, and J. de Leon. 2016. “The Addictive Model of Self- Harming (Non-Suicidal and Suicidal) Behavior.” Frontiers in Psychiatry 7, no. FEB: 1–7. https://​doi.​org/​10.​3389/​fpsyt.​2016.​00008​. Bommersbach, T. J., R. A. Rosenheck, and T. G. Rhee. 2023. “Association of Recent and Past Suicide Attempts With Health-Related Quality of Life.” Journal of Clinical Psychiatry 84, no. 2: 45895. https://​doi.​org/​10.​ 4088/​JCP.​22m14441. Borsboom, D. 2017. “A Network Theory of Mental Disorders.” World Psychiatry 16, no. 1: 5–13. https://​doi.​org/​10.​1002/​wps.​20375​. Cohen, J. 2013. Statistical Power Analysis for the Behavioral Sciences. Academic Press. D'Agostino, A., R. Pepi, M. Rossi Monti, and V. Starcevic. 2020. “The Feeling of Emptiness: A Review of a Complex Subjective Experience.” Harvard Review of Psychiatry 28: 287–295. https://​doi.​org/​10.​1097/​HRP.​ 00000​00000​000269. de la Torre-Luque, A., A. Pemau, W. Ayad-Ahmed, et  al. 2023. “Risk of Suicide Attempt Repetition After an Index Attempt: A Systematic Review and Meta-Analysis.” General Hospital Psychiatry 81: 51–56. https://​doi.​org/​10.​1016/j.​genho​sppsy​ch.​2023.​01.​007. Fulham, L., J. Forsythe, and S. Fitzpatrick. 2023. “The Relationship Between Emptiness and Suicide and Self-Injury Urges in Borderline Personality Disorder.” Suicide and Life-threatening Behavior 53: 362– 371. https://​doi.​org/​10.​1111/​sltb.​12949​. Grilo, C. M., and T. Udo. 2021. “Association of Borderline Personality Disorder Criteria With Suicide Attempts Among US Adults.” JAMA Network Open 4, no. 5: e219389. https://​doi.​org/​10.​1001/​jaman​etwor​ kopen.​2021.​9389. Herron, S. J., and F. Sani. 2022. “Understanding the Typical Presentation of Emptiness: A Study of Lived-Experience.” Journal of Mental Health 31: 188–195. https://​doi.​org/​10.​1080/​09638​237.​2021.​1922645. Herron, S. J., R. Saunders, F. Sani, and J. Feigenbaum. 2024. “The Psychological Emptiness Scale: A Psychometric Evaluation.” BJPsych Open 10, no. 2: e42. https://​doi.​org/​10.​1192/​bjo.​2023.​649. Hudson, C. C., I. Ferguson, K. Fan, T. Björgvinsson, and C. Beard. 2024. “A General Inductive Approach to Characterize Transdiagnostic Experiences of Emptiness.” Journal of Clinical Psychology 80: 1726– 1735. https://​doi.​org/​10.​1002/​jclp.​23689​. Joiner, T. 2005. Why People die by Suicide. Massachusetts: Harvard University Press. Klonsky, E. D. 2007. “The Functions of Deliberate Self-Injury: A Review of the Evidence.” Clinical Psychology Review 27: 226–239. https://​doi.​ org/​10.​1016/j.​cpr.​2006.​08.​002. Klonsky, E. D. 2008. “What Is Emptiness? Clarifying the 7th Criterion for Borderline Personality Disorder.” Journal of Personality Disorders 22: 418–426. https://​doi.​org/​10.​1521/​pedi.​2008.​22.4.​418. 10990879, 2024, 5, D ow nloaded from https://onlinelibrary.w iley.com /doi/10.1002/cpp.70000 by A ndrés Pem au - U niversity O f G lasgow , W iley O nline L ibrary on [23/10/2024]. See the T erm s and C onditions (https://onlinelibrary.w iley.com /term s-and-conditions) on W iley O nline L ibrary for rules of use; O A articles are governed by the applicable C reative C om m ons L icense https://doi.org/10.1016/j.tjem.2018.08.001 https://doi.org/10.1016/j.tjem.2018.08.001 https://doi.org/10.1016/j.rpsmen.2016.06.004 https://doi.org/10.1176/ajp.142.5.559 https://doi.org/10.2147/NDT.S229530 https://doi.org/10.1159/000369937 https://doi.org/10.1159/000369937 https://doi.org/10.1016/j.jpsychires.2012.06.013 https://doi.org/10.3389/fpsyt.2016.00008 https://doi.org/10.4088/JCP.22m14441 https://doi.org/10.4088/JCP.22m14441 https://doi.org/10.1002/wps.20375 https://doi.org/10.1097/HRP.0000000000000269 https://doi.org/10.1097/HRP.0000000000000269 https://doi.org/10.1016/j.genhosppsych.2023.01.007 https://doi.org/10.1111/sltb.12949 https://doi.org/10.1001/jamanetworkopen.2021.9389 https://doi.org/10.1001/jamanetworkopen.2021.9389 https://doi.org/10.1080/09638237.2021.1922645 https://doi.org/10.1192/bjo.2023.649 https://doi.org/10.1002/jclp.23689 https://doi.org/10.1016/j.cpr.2006.08.002 https://doi.org/10.1016/j.cpr.2006.08.002 https://doi.org/10.1521/pedi.2008.22.4.418 https://onlinelibrary.wiley.com/action/rightsLink?doi=10.1002%2Fcpp.70000&mode= 8 of 8 Clinical Psychology & Psychotherapy, 2024 Klonsky, E. D., and A. M. May. 2015. “The Three-Step Theory (3ST): A New Theory of Suicide Rooted in the “Ideation-To-Action” Framework.” International Journal of Cognitive Therapy 8: 114–129. https://​doi.​org/​ 10.​1521/​ijct.​2015.8.​2.​114. Klonsky, E. D., B. Y. Saffer, and C. J. Bryan. 2018. “Ideation-To-Action Theories of Suicide: A Conceptual and Empirical Update.” Current Opinion in Psychology 22: 38–43. https://​doi.​org/​10.​1016/j.​copsyc.​2017.​ 07.​020. Konjusha, A., C. J. Hopwood, A. L. Price, O. Masuhr, and J. Zimmermann. 2021. “Investigating the Transdiagnostic Value of Subjective Emptiness.” Journal of Personality Disorders 35: 788–800. https://​doi.​org/​10.​1521/​pedi_​2021_​35_​510. Linehan, M. M. 1993. “Skills Training Manual for Treating Borderline Personality Disorder. Diagnosis and Treatment of Mental Disorders.” Journal of Psychosomatic Research 43, no. 3. Liu, Y., J. Sareen, J. M. Bolton, and J. L. Wang. 2016. “Development and Validation of a Risk Prediction Algorithm for the Recurrence of Suicidal Ideation Among General Population With Low Mood.” Journal of Affective Disorders 193: 11–17. https://​doi.​org/​10.​1016/j.​jad.​2015.​12.​072. López-Villatoro, J. M., R. Shimano, C. Prittwitz, A. De la Torre, M. Diaz-Marsá, and J. L. Carrasco. 2022. “Predictive Value of the Feeling of Emptiness in Suicidal Behaviour of Emotionally Unstable Disorders.” Clinical Psychology & Psychotherapy 30: 112–118. https://​doi.​org/​10.​ 1002/​cpp.​2781. Martin, J. A., and K. N. Levy. 2022. “Chronic Feelings of Emptiness in a Large Undergraduate Sample: Starting to Fill the Void.” Personality and Mental Health 16: 190–203. https://​doi.​org/​10.​1002/​pmh.​1531. Miller, C. E., M. L. Townsend, N. J. Day, and B. F. Grenyer. 2020. “Measuring the Shadows: A Systematic Review of Chronic Emptiness in Borderline Personality Disorder.” PLoS ONE 15, no. 7: e0233970. https://​doi.​org/​10.​1371/​journ​al.​pone.​0233970. Miller, C. E., M. L. Townsend, and B. F. S. Grenyer. 2021. “Understanding Chronic Feelings of Emptiness in Borderline Personality Disorder: A Qualitative Study.” Borderline Personality Disorder and Emotion Dysregulation 8, no. 1: 24–29. https://​doi.​org/​10.​1186/​s4047​9-​021-​ 00164​-​8. O'Connor, R. C. 2011. “Towards an Integrated Motivational–Volitional Model of Suicidal Behaviour.” In International Handbook of Suicide Prevention: Research, Policy and Practice, edited by R. O'Connmor, S. Platt, and J. Gordon, 181–198. New Jersey: John Wiley & Sons. Otsuka, H., and S. Anamizu. 2019. “Japanese University students' Difficulty in Living and Its Association With Suicidal Ideation.” Asian Journal of Psychiatry 43: 50–52. https://​doi.​org/​10.​1016/j.​ajp.​2019.​ 05.​004. Palomares, N., J. M. López-Villatoro, J. Arévalo, et al. 2020. “The Feeling of Emptiness Questionnaire (CSV). Elaboration and Validation.” Actas Españolas de Psiquiatría 48: 220–227. Pemau, A., C. Marin-Martin, M. Diaz-Marsa, et al. 2024. “Risk Factors for Suicide Reattempt: A Systematic Review and Meta-Analysis.” Psychological Medicine 54, no. 9: 1–8. https://​doi.​org/​10.​1017/​S0033​ 29172​4000904. Posner, K., G. K. Brown, B. Stanley, et al. 2011. “The Columbia–Suicide Severity Rating Scale: Initial Validity and Internal Consistency Findings From Three Multisite Studies With Adolescents and Adults.” American Journal of Psychiatry 168: 1266–1277. https://​doi.​org/​10.​1176/​appi.​ajp.​ 2011.​10111704. Turecki, G., and D. A. Brent. 2016. “Suicide and Suicidal Behaviour.” Lancet 387: 1227–1239. https://​doi.​org/​10.​1016/​S0140​-​6736(15)​00234​-​2. van Orden, K. A., T. K. Witte, K. C. Cukrowicz, S. R. Braithwaite, E. A. Selby, and T. E. Joiner. 2010. “The Interpersonal Theory of Suicide.” Psychological Review 117: 575–600. https://​doi.​org/​10.​1037/​a0018697. World Health Organization. 2023. “Suicide.” https://​www.​who.​int/​ news-​room/​fact-​sheets/​detail/​suicide. Yen, S., J. R. Peters, S. Nishar, et  al. 2021. “Association of Borderline Personality Disorder Criteria With Suicide Attempts: Findings From the Collaborative Longitudinal Study of Personality Disorders Over 10 Years of Follow-Up.” JAMA Psychiatry 78: 187–194. https://​doi.​org/​10.​ 1001/​jamap​sychi​atry.​2020.​3598. Supporting Information Additional supporting information can be found online in the Supporting Information section. 10990879, 2024, 5, D ow nloaded from https://onlinelibrary.w iley.com /doi/10.1002/cpp.70000 by A ndrés Pem au - U niversity O f G lasgow , W iley O nline L ibrary on [23/10/2024]. See the T erm s and C onditions (https://onlinelibrary.w iley.com /term s-and-conditions) on W iley O nline L ibrary for rules of use; O A articles are governed by the applicable C reative C om m ons L icense https://doi.org/10.1521/ijct.2015.8.2.114 https://doi.org/10.1521/ijct.2015.8.2.114 https://doi.org/10.1016/j.copsyc.2017.07.020 https://doi.org/10.1016/j.copsyc.2017.07.020 https://doi.org/10.1521/pedi_2021_35_510 https://doi.org/10.1016/j.jad.2015.12.072 https://doi.org/10.1002/cpp.2781 https://doi.org/10.1002/cpp.2781 https://doi.org/10.1002/pmh.1531 https://doi.org/10.1371/journal.pone.0233970 https://doi.org/10.1186/s40479-021-00164-8 https://doi.org/10.1186/s40479-021-00164-8 https://doi.org/10.1016/j.ajp.2019.05.004 https://doi.org/10.1016/j.ajp.2019.05.004 https://doi.org/10.1017/S0033291724000904 https://doi.org/10.1017/S0033291724000904 https://doi.org/10.1176/appi.ajp.2011.10111704 https://doi.org/10.1176/appi.ajp.2011.10111704 https://doi.org/10.1016/S0140-6736(15)00234-2 https://doi.org/10.1037/a0018697 https://www.who.int/news-room/fact-sheets/detail/suicide https://www.who.int/news-room/fact-sheets/detail/suicide https://doi.org/10.1001/jamapsychiatry.2020.3598 https://doi.org/10.1001/jamapsychiatry.2020.3598 https://onlinelibrary.wiley.com/action/rightsLink?doi=10.1002%2Fcpp.70000&mode= Relationship Between the Feeling of Emptiness and Suicide Reattempt: Conclusions From Cross-­Sectional and Longitudinal Analyses ABSTRACT 1   |   Introduction 2   |   Methods 2.1   |   Participants 2.2   |   Instruments 2.3   |   Data Analysis 2.3.1   |   Cross Sectional 2.3.2   |   Survival Analysis 3   |   Results 4   |   Discussion Acknowledgements Ethics Statement Conflicts of Interest Data Availability Statement References