Publications of Interest

Suicide, Trauma, and Dissociation

Lynn Hazard, LCSW, POI Editor

Lynn Hazard, POI Editor

This quarter’s POI theme is suicide associated with trauma and/or dissociation. This is an important theme for me, after having lost two family members in less than one year to suicide – both having had histories of childhood trauma. Professionals and survivors need to be aware of the increased risks for, along with the correlations between, trauma and suicide. When someone can face the past, learn to appreciate themselves for having survived, and develop ways to self-regulate and integrate, then a path is opened to true healing. Please take care of yourselves and, if this issue distresses you, please contact your professional supports or contact the suicide prevention services in your country

Firoozabadi, A., Jahromi, L.R., and Yaghmaie, S. (2018). Prevalence of dissociative experiences in those referred to emergency psychiatric centers after attempting suicide. Journal of Hospital Practice and Research, 3(1):22-27. DOI: 10.1517/hpr.2018.05

Abstract
Background: Dissociation is a symptom that can be related to traumatic childhood events. Dissociation in some cases is categorized in a distinct subgroup from other psychiatric disorders. Objective: The purpose of this study was to investigate the prevalence of dissociative experiences in patients who have attempted suicide and who have referred to an emergency psychiatric center. Methods: This was a cross-sectional epidemiological study in which dissociative experiences were evaluated in 98 patients who referred to Ibn Sina and Hafez hospitals after attempting suicide. In addition to determining the prevalence of these experiences, the relationship between the symptoms and variables such as sex, age, marital status, education, and suicide risk was determined. Results: There was significant difference in the level of disappointment between married and single patients (P=0.047). The mean disappointment score for the overall population was 11.92, which is in the normal range. There was no significant relationship between dissociation score and level of disappointment (P=0.933). The prevalence of dissociative experiences was found to decrease as the age of the patients increased (P=0.006). There was no significant difference between rate of suicide as reflected in the measurement of disappointment and dissociative symptoms There was no significant relationship between DES score and other variables. Conclusion: One cause of psychological pressure in deciding to attempt suicide is family conflict. Many individuals who attempt suicide did not have a thought-out desire to take their lives, but attempted it impulsively in response to a periodic stressor.

Ford, J.D., Chark, R., Modrowski, C.A., & Kerig, P.K. (2018). PTSD and dissociation symptoms as mediators of the relationship between polyvictimization and psychososical and behavioral problems among justice-involved adolescents. Journal of Trauma & Dissociation, 19(3):325-346. Download at https://doi.org/10.1080/15299732.2018.1441354

Abstract
Polyvictimization (PV) has been shown to be associated with psychosocial and behavioral impairment in community and high risk populations, including youth involved in juvenile justice. However, the mechanisms accounting for these adverse outcomes have not been empirically delineated. Symptoms of posttraumatic stress disorder (PTSD) and dissociation are documented sequelae of PV and are associated with a wide range of behavioral/emotional problems. This study used a cross-sectional research design and bootstrapped multiple mediation analyses with self-report measures completed by a large sample of justice-involved youth (N=809, ages 12-19 years old, 27% female, 46.5% youth of color) to test the hypotheses that PTSD and dissociation symptoms mediate the relationship between PV and problems with anger, depression/anxiety, alcohol/drug use, and somatic complaints after controlling for the effects of exposure to violence and adversities related to juvenile justice involvement. As hypothesized, PTSD symptoms mediated the relationship of PV with all outcomes except alcohol/drug use problems (which had an unmediated direct association with PV). Partially supporting study hypotheses, dissociation symptoms mediated the relationship between PV and internalizing problems (i.e., depression anxiety; suicide ideation). Implications are discussed for prospective research demarcating the mechanisms linking PV and adverse outcomes in juvenile justice and other high risk populations.

Xie, P., Wu, K., Zheng, Y., et. al. (2017). Prevalence of childhood trauma and correlations between childhood trauma, suicidal ideation, and social supports inpatients with depression, bipolar disorder, and schizophrenia in southern China. Journal of Affective Disorders, Vol. 228:41-48. Download at https://doi.org/10.1016/j.jad.2017.11.011.

Abstract
Background: Childhood trauma has long-term adverse effects on physical and psychological health. Previous studies demonstrated that suicide and mental disorders were related to childhood trauma. In Chine, there is insufficient research available on childhood trauma in patients with mental disorders. Methods: Outpatients were recruited from a psychiatric hospital in southern China, and controls were recruited from local communities. The demographic questionnaire, the Childhood Trauma Questionnaire – Short Form (CTQ-SF), and the Social Support Rating Scale (SSRS) were completed by all participants, and the Self-rating Idea of Suicide Scale (SIOSS) were completed only by patients. Prevalence rates of childhood trauma were calculated. Druskal-Wallis test and Dunnet test were used to compare CTQ-SF and SSRS scores between groups. Logistic regression was used to control demographic characteristics ad examine relationships between diagnosis and CTQ-SF and SSRS scores. Spearman’s rank correlation test was conducted to analyze relationships between suicidal ideation and childhood trauma and suicidal ideation and social support. Results: The final sample comprised 229 patients with depression, 102 patients with bipolar, 216 patients with schizophrenia, and 132 health controls. In our sample, 55.5% of the patients with depression, 61.8% of the patients with bipolar disorder, 47.2% of the patients with schizophrenia, and 20.5% of the healthy people reported at least one type of trauma. In patient groups, physical neglect (PN) and emotional neglect (EN) were most reported, and sexual abuse (SA) and physical abuse (PA) were least reported. After controlling for demographic characteristics, mental disorders were associated with higher CTQ-SF scores and lower SSRS scores. CTQ-SF scores and number of trauma types were positively correlated with the SIOSS score. Negative correlations existed between SSRS scores and SIOSS score. Limitations: Our sample may not be sufficiently representative. Some results might have been interfered by demographic characteristics. The SIOSS was not completed by controls. Data from self-report scales were not sufficiently objective. Conclusions: In southern China, childhood trauma is more severe and more prevalent in patients with mental disorders (depression, bipolar and schizophrenia) than healthy people. Among patients with mental disorders in southern China, suicidal ideation is associated with childhood trauma and poor social support.

Xiang Ng, Q., Zheng Jie Yong, B., Yin Xian Ho, C., Yutong Lim, D., & Yeo, W-S. (2018). Early Life sexual abuse is associated with increased suicide attempts: an update meta-analysis. Journal of Psychiatric Research, Vol. 99:129-141.
Download at https://doi.org/10.1016/j.jpsychires.2018.02.001

Abstract
Suicide is an emerging, yet preventable global health issue associated with significant mortality. Identification of underlying risk factors and antecedents may inform preventive strategies and interventions. This study serves to provide an updated meta-analysis examining the extent of association of early life sexual abuse with suicide attempts Use the keywords [early abuse OR childhood abuse OR sexual OR rape OR molest* OR violence OR trauma OR PTSD] AND [suicide* OR premature OR unnatural OR deceased OR died OR mortality], a preliminary search on PubMed, Ovid, PsychINFO, Web of Science and Google Scholar databases yielded 12,874 papers published in English between 1-Jan-1988 and 1-June-2017. Of these, only 47 studies were included in the final meta-analysis. The 47 studies (25 cross-sectional, 14 cohort, 6 case-control and 2 twin studies) contained a total of 151,476 subjects. Random-effects meta-analysis found early life sexual abuse to be a significant risk factor for suicide attempts, compared to baseline population (pooled OR 1.89, 95% CI: 1.66 to 2.12, p<0.001). Subgroup analyses of cross-sectional and longitudinal studies showed similar findings of increased risk as they yielded ORs of 1.98 (95% CI: 1.70 to 2.25, p<0.001) and 1.65 (95% CI: 1.37 to 1.93, p<0.001), respectively. In both cross-sectional and longitudinal studies, childhood sexual abuse was consistently associated with increased risk of suicide attempts. The findings of the present study provide strong grounds for funding public policy planning and interventions to prevent sexual abuse and support its victims. Areas for future research should include preventive and treatment strategies and factors promoting resilience following childhood sexual abuse. Future research on the subject should have more robust controls and explore the differential effects of gender and intra- versus extra-familial sexual abuse.

Stein, M.B., Campbell-Sills, L., Ursano, R.J., et. al. (2018). Childhood maltreatment and lifetime suicidal behaviors among new soldiers in the US Army: results from the Army study to assess risk and resilience in service members (Army STARRS). The Journal of Clinical Psychiatry [01 Mar 2018, 79(2)]. DOI: 10.4088/JCP.16m10900.

Abstract
Understanding suicide risk is a priority for the US military. We aimed to estimate associations of childhood maltreatment with pre-enlistment suicidal behaviors in new Army soldiers. Cross-sectional survey data from 38,237 soldiers reporting for basic training from April 2011 through November 2012 were analyzed. Scales assessing retrospectively reported childhood abuse and neglect were derived and subjected to latent class analysis, which yielded 5 profiles: No Maltreatment, Episodic Emotional Maltreatment, Frequent Emotional/Physical Maltreatment, Episodic Emotional/Sexual Abuse, and Frequent Emotional/Physical/Sexual Maltreatment. Discrete-time survival analysis was used to estimate associations of maltreatment profiles with suicidal behaviors (assessed with modified Columbia-Suicide Severity Rating Scale), adjusting for sociodemographic and mental disorders. Nearly 1 in 5 new soldiers was classified as experiencing childhood maltreatment. Relative to No Maltreatment, all multivariate maltreatment profiles were associated (P values <0.001) with elevated odds of lifetime suicidal ideation (adjusted odds rations [AORs] = 3.10-4.93), plan (AORs = 3.75-10.77), attempt (AORs = 3.60-15.95), and onset of plan among those with ideation (AORs = 1.40-3.10). Several profiles also predicted attempts among those with plans (AORs = 2.01-2.47), and Frequent Emotional/Physical/Sexual Maltreatment predicted unplanned attempts among ideates (AOR = 5.32). Adjustment for mental disorders attenuated but did not eliminate these associations. Childhood maltreatment is strongly associated with suicidal behavior among new soldiers, even after adjusting for intervening mental disorders. Among soldiers with lifetime ideation, certain maltreatment profiles are associated with elevated odds of subsequently planning and/or attempting suicide. Focus on childhood maltreatment might reveal avenues for risk among new soldiers.

Bjorkenstam, E., Hjern, A., Bjorkenstam, C., et. al. (2018). Association of cumulative childhood adversity and adolescent violent offending with suicide in early adulthood. Journal of the American Medical Association Psychiatry, 75(2):185-193.
Download at https://doi.org/doi:10.1001/jamapsychiatry.2017.3788

Abstract
Importance: Childhood adversity (CA) is associated with an increased risk of suicide in young adulthood that might be explained by maladaptive trajectories during adolescence. Although adolescent violent offending is linked with suicide, little is known about its role in the association between CA and suicide. Objective: To examine whether adolescent violent offending mediates the association between CA and suicide in early adulthood. Design, Setting, and Participants: This population-based, longitudinal cohort study with a follow-up time spanning 5 to 9 years included 476,103 individuals in Sweden between 1984 and 1988. The study population was prospectively followed up from 20 years of age until December 31, 2013, with respect to suicide. Data analysis was performed from January 1, 1984 to December 31, 2013. Exposures: Resisted-Based CAs included parental death, parental substance abuse and psychiatric disorder, parental criminal offending, parental separation, public assistance recipiency, child welfare intervention, and residential instability. Adolescent violent offending was defined as being convicted of a violent crime between the ages of 15 and 19 years. Main Outcomes and Measures: Estimates of risk of suicide after 20 years of age (from 2004 if born in 1984 and from 2008 if born in 1988) until the end of 2013 were calculated as incidence rate rations (IRRs) with 95% CIs using Poisson regression analysis. Adjustments were made for demographics and psychiatric disorder. In addition, binary mediation analysis with logistic regression was used. Results: A total of 476,103 individuals (231,699 [48%] female) were included in the study. Those with a conviction for violent offending had been exposed to all CAs to a greater extend that those with no violent offending. Cumulative CA was associated with risk of suicide in non convicted (adjusted IRR, 2.4; 95% CI, 1.5-3.9) and convicted youths, who had a higher risk of suicide (adjusted IRR, 8.5; 95% CI, 4.6-15.7). Adolescent violent offending partly mediated the association between CA and suicide. Conclusions and Relevance: Individuals with a history of CA who also engaged in violent offending in adolescence have a high risk of suicide. Interventions to prevent externalizing behavior during childhood and increased support to youths with delinquent behavior may have the potential to prevent suicide related to CA.

Bromet, E.J., Nock, M.K., & Saha, S. (2017). Association between psychotic experiences and subsequent suicidal thoughts and behaviors: a cross-national analysis from the World Health Organization world mental health surveys. Journal of the American Medical Association Psychiatry 74(11):1136-1144.
Download at https://doi.org/doi:10.1001/jamapsychiatry.2017.2647.

Abstract
Importance: Community-based studies have linked psychotic experiences (PEs) with increased risk of suicidal thoughts and behaviors (STBs). However, it is not knows if these associations vary across the life course or if mental disorders contribute to these associations. Objective: To examine the temporal association between PEs and STBs across the life span as well as the influence of mental disorders (antecendent to the STBs) on these associations. Design, Setting, and Participants: A total of 33,370 adult respondents across 19 countries from the World Health Organization World Mental Health Surveys were assessed for PEs, STBs (ie. Ideation, plans, and attempts), and 21 DSM-IV mental disorders Discrete-time survival analysis was used to investigate the association of Pas with subsequent onset of STBs. Main Outcomes and Measures: Prevalence and frequency of STBs and Yes, and odds ratios and 95% CIs. Results: of 33,370 included participants, among those with PEs (n=2488), the lifetime prevalence (SE) of suicidal ideation, plans, and attempts was 28.5% (1.3), 10.8% (0.7), respectively. Respondents with 1 or more PEs had 2-fold increased odds of subsequent STBs after adjusting for antecedent or intervening mental disorders (suicidal ideation: odds ratio, 2.2: 95% CI, 1.8-2.6; suicide plans: odds ratio, 2.1; 95%CI, 1.7-2.6; and suicide attempts: odds ratio, 1.9; 95% CI, 1.5-2.5). There were significant does-response relationships of number of PE types with subsequent STBs that persisted after adjustment for mental disorders. Although Yes were significant predictors of subsequent STBs onset across all life stages, associations were strongest in individuals 12 years and younger. After adjustment for antecedent mental disorders, the overall population attributable risk proportions for lifetime suicidal ideation, plans, ad attempts associated with temporally prior PEs were 5.3%, 5.7%, and 4.8% respectively. Conclusions and Relevance: Psychotic experiences are associated with elevated odds of subsequent STBs across the life course that cannot be explained by antecedent mental disorders. These results highlight the importance of including information about PEs in screening adjustments designed to predict STBs.

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