Which symptoms of post-traumatic stress disorder are associated with suicide attempts?
Introduction
There has been an increasing interest in the relationship between post-traumatic stress disorder (PTSD) and suicide. Several studies have consistently shown that PTSD is associated with increased likelihood of suicidal behavior (Cougle et al., 2009, Davidson et al., 1991, Ferrada-Noli et al., 1998, Helzer et al., 1987, Kessler et al., 1995, Kotler et al., 2001, Nepon et al., 2010, Sareen et al., 2005, Tarrier and Gregg, 2004, Wilcox et al., 2009, Wunderlich et al., 1998). In a study by Sareen et al. (2005), which examined the relationship of individual anxiety disorders with both suicidal ideation and suicide attempts in a nationally representative sample, it was found that PTSD was the only anxiety disorder that was independently associated with both suicidal ideation and suicide attempts. A study by Nepon et al. (2010) which adjusted for all 10 DSM-IV personality disorders, as well as Axis I disorders, found that both PTSD and panic disorder were significantly associated with lifetime suicide attempts.
There is a small body of literature that has examined the relationship between the three symptom clusters of PTSD (re-experiencing, avoidance, and hyperarousal) and suicidal behavior. However, there is no clear evidence as to which of these clusters are more or less associated with suicide attempts. A study by Bell and Nye (2007) which examined a sample of 50 Vietnam combat veterans found that the re-experiencing symptom cluster was more strongly associated with suicidal ideation, whereas the hyperarousal and avoidance symptoms were not. This study, however, did not examine suicide attempts as an outcome. One other study by Ben-Ya’acov and Amir (2004) examined the relationship between PTSD symptoms and suicide risk, finding that in a community sample of 103 men with no known psychopathology, high levels of arousal symptoms may increase suicide risk.
Both of the studies were limited by small sample sizes and the use of community or veteran samples and therefore may have been influenced by selection bias. Suicide attempts have been consistently identified as one of the strongest risk factors for eventual suicide (Tidemalm, Langstrom, Lichtenstein, & Runeson, 2008), and therefore it is important to examine their relationship with PTSD symptoms. To the best of our knowledge, our study will be the first to examine PTSD symptom clusters as well as individual PTSD symptoms in relation to suicide attempts.
The aim of our study was to address these limitations using data from the National Epidemiologic Survey of Alcohol and Related Conditions (NESARC) to determine the relationship between suicide attempts and the three DSM-IV symptom clusters of PTSD (re-experiencing, avoidance, and hyperarousal). Secondary objectives were to determine whether any of the individual symptoms listed under each symptom cluster was independently associated with suicide attempts.
Based on previous literature, we hypothesized that the hyperarousal and re-experiencing symptoms would be more strongly associated with suicide attempts than would avoidance symptoms (Bell and Nye, 2007, Ben-Ya’acov and Amir, 2004). Investigating the relationship between specific symptoms and suicide attempts will help refine and extend our understanding of the elevated risk of suicidal behavior observed with PTSD.
Section snippets
Sample
Data were obtained from Wave 2 (2004–2005) of the National Epidemiologic Survey of Alcohol and Related Conditions (NESARC). The NESARC is a nationally representative survey of noninstitutionalized US civilians aged 20 and over. All variables used in this study came from the Wave 2 assessment. Interviews were administered in person, and the overall response rate was 70.2%. The sample size is N = 34 653. As demonstrated in Fig. 1, of the 34 653 participants, 2463 met criteria for lifetime PTSD and
Results
Table 1 compares the demographics and mental disorders in the PTSD with no suicide attempt group and the group with suicide attempt after a diagnosis of PTSD. Prevalence of lifetime mental disorders in the group that attempted suicide with a diagnosis of PTSD was increased as compared to the PTSD with no suicide attempt group.
Table 2 identifies the different NESARC questions used to evaluate the specific DSM IV symptoms of PTSD, as well as the associations between the individual PTSD symptoms
Discussion
To the best of our knowledge, the present study is the first that examines the associations between the specific symptoms of DSM-IV PTSD and suicide attempts. We found that among the three PTSD symptom clusters, symptoms of re-experiencing were significantly associated with suicide attempts, and contrary to our original hypothesis avoidance symptoms were also significantly associated with suicide attempts. This was true even after adjusting for sociodemographics, any mood, any substance, any
Conclusions
It is important for clinicians to identify individuals with PTSD who are at higher risk for suicide attempts. The results of this cross-sectional study suggest that certain symptoms of PTSD, such as symptoms from the avoidance and re-experiencing symptom clusters, may predict suicide attempts. However, further studies with longitudinal designs are needed to clarify the exact relationship between PTSD symptoms and suicide attempts.
Acknowledgements
The authors would like to thank Ms. Sarah Marie Raposo, B.A. (Hons.) for editing this manuscript. Hayley Chartrand is supported by a University of Manitoba Graduate Fellowship and a Manitoba Graduate Scholarship. Dr. Bolton is supported by a Manitoba Health Research Council Establishment grant and a CIHR New Investigator Award. Dr. Sareen is supported by a Manitoba Health Research Council grant.
References (26)
- et al.
Post-traumatic symptoms and suicide risk
Personality and Individual Differences
(2004) - et al.
Cardiac response to relevant stimuli as an adjunct in diagnosing post-traumatic stress disorder: replication and extension
Behavior Therapy
(1989) - et al.
Anxiety disorders and suicidality in the national comorbidity survey-replication
Journal of Psychiatric Research
(2009) Anxiety sensitivity and panic disorder
Biological Psychiatry
(2002)Anxiety and its disorders: the nature and treatment of anxiety and panic
(2002)- et al.
Cardiovascular manifestations of post-traumatic stress disorder
Journal of the National Medical Association
(2007) - et al.
Specific symptoms predict suicidal ideation in Vietnam combat veterans with chronic post-traumatic stress disorder
Military Medicine
(2007) - et al.
Post-traumatic stress disorder in the community: an epidemiological study
Psychological Medicine
(1991) - et al.
Cognitive factors in traumatic stress reactions: predicting PTSD symptoms from anxiety sensitivity and beliefs about harmful events
Behavioural and Cognitive Psychotherapy
(2000) - et al.
Suicidal behavior after severe trauma. Part 1. PTSD diagnoses, psychiatric comorbidity and assessments of suicidal behavior
Journal of Traumatic Stress
(1998)
Post-traumatic stress disorder in the general population: findings of the epidemiologic catchment area survey
The New England Journal of Medicine
Suicide risk in schizophrenia: explanatory models and clinical implications, the schematic appraisal model of suicide (SAMS)
Psychology and Psychotherapy: Theory, Research and Practice
Utility of psychophysiology measurement in the diagnosis of post-traumatic stress disorder: results from a department of veteran's affairs cooperative study
Journal of Consulting and Clinical Psychology
Cited by (42)
Toward an integrative model of transdiagnostic risk factors and suicide: A network comparison of psychiatric outpatients
2022, Journal of Psychiatric ResearchLongitudinal relationships among posttraumatic stress disorder symptom clusters in response to positive memory processing
2022, Journal of Behavior Therapy and Experimental PsychiatryCitation Excerpt :Such avoidance is repeatedly reinforced and difficult to extinguish over time (Orr et al., 2000), which in turn maintains long-term PTSD symptom severity (Tull & Roemer, 2003). Further, PTSD's avoidance symptoms have been associated with other health correlates that contribute to PTSD such as psychological distress (Plumb, Orsillo, & Luterek, 2004), alcohol use (Dworkin, Wanklyn, Stasiewicz, & Coffey, 2018), and suicide attempts (Selaman, Chartrand, Bolton, & Sareen, 2014). The dynamic interplay between PTSD symptom clusters (i.e., how symptoms influence each other longitudinally), especially the role of PTSD's avoidance symptoms in influencing other PTSD symptomatology, has been addressed in the context of trauma-focused treatments that target negative/traumatic memories (Schnurr, 2017), but not in the context of trauma treatments targeting positive memories.
Suicide risk in people with post-traumatic stress disorder: A cohort study of 3.1 million people in Sweden
2021, Journal of Affective DisordersCitation Excerpt :PTSD could plausibly lead to feelings of defeat and entrapment, through the sense that recurrent symptoms of intrusive thoughts, nightmares and flashbacks are inescapable (Panagioti et al., 2012). Individuals with PTSD may also experience heightened physiological reactions when reminded of their trauma (Bedi and Arora, 2007), which when combined with autonomic hyperarousal, result in maintenance of perceptions of ongoing threat, entrapment and defeat (Selaman et al., 2014). Various strands of empirical evidence appear to support a role for defeat, entrapment and hyperarousal.
Associations between PTSD symptoms and suicide risk: A comparison of 4-factor and 7-factor models
2020, Journal of Psychiatric ResearchAn examination of PTSD symptoms and their effects on suicidal ideation and behavior in non-treatment seeking veterans
2019, Psychiatry ResearchCitation Excerpt :Past studies using DSM-IV and DSM-5 symptom clusters for PTSD, however, have found that the Re-experiencing (Barr et al., 2016; Bell and Nye, 2007; Boffa et al., 2017), Hyperarousal (Brier et al., 2015; Pennings et al., 2017), and Numbing (Boffa et al., 2017; Pennings et al., 2017) symptoms are associated with increased suicidal ideation. On the other hand, the Avoidance (Barr et al., 2016; Legarreta et al., 2015; Selaman et al., 2014), Dysphoria (Legarreta et al., 2015), Numbing (Pennings et al., 2017), Hyperarousal (Briere et al., 2015), and Re-experiencing (Boffa et al., 2017; Selaman et al., 2014; Watkins et al., 2017) symptoms have all been linked to suicidal behavior. Overall, suicide risk was found to be higher with elevated levels of arousal and lower levels of avoidance symptoms (Ben-Ya'acov and Amir, 2004).