Executive Function and Self-Injurious Thoughts and Behaviors: A Systematic Review and Meta-Analysis

Although executive functioning (EF) deficits have been implicated in self-injurious thoughts and behaviors (SITBs), the strength of their associations remain unclear. Few mechanisms reliably differentiating between suicidal thoughts and suicide attempts have been identified. The degree to which EF deficits may differentiate suicidal thoughts from behavior is undetermined.

PubMed and PsycInfo were searched from inception through June 4, 2025. Two reviewers independently identified studies on core EFs (inhibitory control, cognitive flexibility, and working memory) and their subcomponents in relation to SITBs. Associations between each core EF and their composite parts in relation to suicidal ideation, suicide attempts, and nonsuicidal self-injury were extracted. Hedges' g was derived from random-effects meta-analyses.

A total of 127 studies were included. Deficits in inhibitory control, cognitive flexibility, and working memory were associated with suicidal ideation (gs = |0.15|-|0.23|) and suicide attempts (gs = |0.21|-|0.28|). Medium pooled effects were observed for cognitive flexibility (g = 0.52, 95% CI [0.10 to 0.93]) and working memory (g = -0.69, 95% CI [-1.00 to -0.38]) in relation to nonsuicidal self-injury. Sensitivity analyses suggested that task switching and response inhibition were specifically related to suicidal ideation, whereas working memory and attentional control were specific to suicide attempts.

While other neurocognitive functions have also been associated with SITBs, EF deficits may be particularly promising candidate mechanisms. Future longitudinal work will be important for establishing prognostic value to inform selection of brain regions to target with neuromodulation treatment paradigms.