Which symptoms of post-traumatic stress disorder are associated with suicide attempts?

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Highlights

  • Association of symptom clusters of PTSD and specific PTSD symptoms with suicide attempts.

  • Re-experiencing and avoidance clusters are associated with suicide attempts (SA) in individuals with PTSD.

  • Having physical reactions by reminders of the trauma associated with SA in individuals with PTSD.

  • Unable to recall aspects of the trauma associated with SA in individuals with PTSD.

  • Having the sense of a foreshortened future is associated with SA in individuals with PTSD.

Abstract

Individuals with post-traumatic stress disorder are at increased risk for suicide attempts. The present study aimed to determine which of the specific DSM-IV symptoms of post-traumatic stress disorder (PTSD) are independently associated with suicide attempts. Data came from Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). The NESARC has a sample size of N = 34 653. The full sample size included in analyses was 2322 individuals with PTSD. Among individuals with lifetime PTSD, after adjusting for sociodemographic factors, as well as any mood, substance, personality, or anxiety disorder (excluding PTSD), increasing numbers of re-experiencing and avoidance symptoms were significantly correlated with suicide attempts. Of the specific symptoms, having physical reactions by reminders of the trauma, being unable to recall some part of it, and having the sense of a foreshortened future, were all associated with suicide attempts. These findings will help extend our understanding of the elevated risk for suicide attempts in individuals with PTSD.

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.

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