Panic symptoms and elevated suicidal ideation and behaviors among trauma exposed individuals: Moderating effects of post-traumatic stress disorder
Introduction
Death by suicide claims over 30,000 lives in the United States and nearly 1 million lives worldwide each year, making it the 11th leading cause of death in the United States and 14th leading cause of death worldwide (see [37] for a review). Despite declines in suicide rates in response to treatment [43], the global burden of suicide has been projected to grow in the coming decades [31], [32]. Death by suicide is most strongly predicted by suicide attempt, which is in turn predicted by suicidal ideation and behaviors [26], [60]. Therefore, identifying malleable factors that predict suicidal ideation and behaviors may hold promise in reducing the personal and societal burden of suicide.
An estimated 22% of all suicide attempts are related to exposure to a psychologically traumatic event [51]. Trauma exposure is highly prevalent (61% to 80%; [27], [28]) and has been consistently linked with increased risk for suicide [16], [40]. Some researchers have posited the relationship between trauma exposure and suicidal ideation and behaviors to be mediated by factors such as depression and PTSD [55], [59]. However, this is contradicted by epidemiological investigations demonstrating significant effects of trauma exposure on suicidal ideation and behaviors beyond the effects of psychopathology [34]. In a seminal review, Stein et al. [51] analyzed trauma exposure and suicidal ideation and behaviors data from 102,245 adults in 21 countries. Findings revealed that trauma exposed individuals were at greater risk for suicidal ideation and suicide attempt even when controlling for PTSD. Similarly, Belik et al. [5] analyzed data from 5877 American adults collected through the National Comorbidity Survey and found that traumatic event exposure predicted suicidal ideation and behaviors above and beyond the effects of psychiatric disorders. Collectively, these findings indicate that psychiatric diagnoses are insufficient to explain the full relationship between trauma exposure and suicidal ideation and behaviors, positing the need for a more nuanced investigation of trauma-relevant factors that may elevate suicidal ideation and behaviors
One risk factor that may be particularly salient to suicidal ideation and behaviors among trauma exposed individuals is panic, an abrupt surge of fear or discomfort that peaks within minutes [1]. Using data from the Epidemiological Catchment Area (ECA) study, Weissman et al. [60] were among the first to report that individuals with panic disorder (PD) were at significantly greater risk for suicide when compared to other psychiatric conditions. A number of studies since have supported a relationship between PD and suicidal ideation and behaviors (e.g., [10], [25], [49]). However, some studies investigating this phenomenon among “pure” PD samples without comorbid diagnoses have failed to find a significant association [4], [39], [44]. These discrepant findings suggest that panic attacks in the presence of co-occurring stressors or psychopathology, such as trauma exposure and PTSD, may be associated with elevated suicidal ideation and behaviors, and not PD per se.
Non-PD related panic attacks appear to be both highly prevalent among trauma exposed individuals as well as indicative of more severe trauma-relevant symptomology. High rates of panic have been reported among trauma exposed young adults [7], individuals reporting symptoms of acute stress disorder in hospital settings [9], [36], rape victims within 72 h of the assault [42], and individuals seeking treatment for trauma-related symptomology [13]. Trauma exposed adults who report experiencing non-PD panic attacks have also been shown to experience greater trauma-relevant symptoms and overall distress. Marshall-Berenz et al. [30] assessed 91 trauma exposed adults and found that the experience of panic predicted greater PTSD re-experiencing and hyperarousal symptoms when controlling for relevant covariates. In addition, Cougle et al. [11] examined data from the National Comorbidity Study — Replication (NCS-R) and found that individuals who experienced non-PD panic reported greater re-experiencing and avoidance/numbing symptoms of PTSD, greater disability, and detriments in work performance.
It is clear that psychiatric diagnoses are insufficient to explain the elevated suicide risk among trauma exposed individuals [5], [34], [51] and that trauma exposed individuals who experience non-PD panic symptoms report greater adverse trauma-related outcomes [11], [30]. However, research to date has not evaluated whether non-PD panic is associated with elevated suicide risk among these individuals. Panic is a highly treatable psychiatric symptom [46], [47], [54]. Therefore, determining whether the presence of non-PD panic contributes to suicidal ideation and behaviors in this high-risk population is crucial for effective treatment following trauma exposure.
The current study seeks to investigate the association of non-PD related panic attacks on suicidal ideation and behaviors among a trauma exposed sample of community participants using pre-treatment, cross-sectional data from participants enrolled in a smoking cessation study. It was hypothesized that trauma exposed individuals who report greater current panic symptoms would also report greater suicidal ideation and behaviors. Additionally, extant research has linked PTSD with increased suicidal ideation and behaviors [53] and has demonstrated individuals with a PTSD diagnosis who experience panic to have greater symptom severity [11]. Therefore, it was hypothesized that the relationship between panic and suicidal ideation and behaviors would be stronger for trauma exposed individuals with a PTSD diagnosis compared to those without a PTSD diagnosis.
Section snippets
Participants
The current sample included 421 community adults from a larger study investigating the effects of a smoking cessation program. Participants were recruited at two sites (University of Vermont, Burlington, VT and Florida State University, Tallahassee, FL) at which identical procedures were implemented. All data used in the current investigation were collected at baseline prior to the smoking cessation program. Eligibility requirements included: minimum age of 18 years, daily smoking for at least
Sample descriptives
Means, standard deviations, and intercorrelations for the variables included in these analyses can be found in Table 1. Mean scores for the IDAS panic, dysphoria, and suicidal ideation and behaviors subscales were comparable to those found in other samples of community adults [58] as was number of trauma types experienced [14], [57]. Current panic symptoms, as assessed by IDAS panic, were endorsed by 67.9% of participants. Criteria for a current PTSD diagnosis were met for 6.4% of participants.
Discussion
The current study is the first to establish a relationship between non-PD related panic symptoms and suicidal ideation and behaviors among a trauma exposed sample. The correlation observed between the IDAS panic and suicidality subscales was consistent with previous research in community samples [58]. Moreover, these results demonstrate that trauma exposed individuals who report panic symptoms are at heightened risk for suicidal ideation and behaviors even when controlling for depressed mood
Acknowledgment
The present study was funded by a grant from the NIH (R01-MH076629). We thank the fourth and fifth authors who provided the data necessary for our analysis.
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