PTSD/Suicide: Conceptualization and Assessment Beeta Y. Homaifar, Ph.D.

PTSD/Suicide: Conceptualization and Assessment Beeta Y. Homaifar, Ph.D.

PTSD/Suicide: Conceptualization and Assessment Beeta Y. Homaifar, Ph.D. Hal S. Wortzel, M.D. VISN 19 Mental Illness, Research, Education and Clinical Center (MIRECC); University of Colorado, School of Medicine, Department of Psychiatry Disclosure Statement This presentation is based on work supported by the Department of Veterans Affairs, but does not necessarily represent the views of the Department of Veterans

Affairs or the United States Government Disclaimer Information during this presentation is for educational purposes only it is not a substitute for informed medical advice or training. You should not use this information to diagnose or treat a mental health problem without consulting a qualified professional/provider Synopsis of Presentation The scope of Veteran suicide

PTSD/Suicide Conceptual model of suicide Suicide risk assessment Questions and Comments The Scope of Veteran Suicide Suicide in the Veteran Population Approximately 20% of all suicides are identified as current or former military (National Violent Death Reporting System) About 5 deaths from suicide per day among Veterans

receiving care in VHA (VA Serious Mental Illness Treatment, Research and Evaluation Center) About 33% of Veterans who die by suicide have a history of previous attempts (VA National Suicide Prevention Coordinator reports) Sources of Increased Suicide Risk Increased risk for suicide has been noted in the following Those receiving outpatient mental health services (Desai et al 2008)

Those who have received psychiatric discharge (Desai et al 2005) Patients receiving depression treatment (Ziven et al 2007) Men with bipolar disorder and women with substance use disorders (Ilgen et al 2010) Risk of Suicide Attempt Increased risk for suicide attempts has been noted in the following

Those with psychiatric conditions (e.g., PTSD, Depression), prior suicide attempt, alcohol misuse, and history of sexual abuse Suicidal Ideation 21.6% of OEF/OIF Veterans with psychiatric disorders reported having had suicidal ideation in the past two weeks Pietrzak et al, 2010 PTSD/Suicide

What do we know about PTSD/Suicide? Explosion of research in this area in the last ~5-10 years The relationship is complicated Panagioti et al, 2012 Krysinska & Lester, 2010 Subthreshold PTSD matters, too Its not just PTSD those with subthreshold PTSD are 3x more likely to report suicidal

ideation compared to healthy controls Jakupcak et al, 2011 Factors contributing to risk in this population

Comorbid disorders, especially depression Impulsive behavior Feelings of guilt/shame Pre-deployment traumatic experiences Re-experiencing symptoms Combat exposure Tarrier et al, 2004; Bell & Nye, 2007; Kramer et al, 1994; FerradaNoli et al, 1998; Tiet et al, 2006 Conceptual Model of Suicide in the Context of PTSD

Interpersonal Theory of Suicide Those Who Desire Suicide Perceived Burdensomeness Those Who Are Capable of Suicide Thwarted Belongingness Serious Attempt or Death by Suicide Joiner, 2005

Perceived Burdensomeness My death is worth more than my life to my loved ones/family/society. Thwarted Belongingness No one cares. Im all alone. Those Capable of Suicide Habituation to painful stimuli (e.g., suicide attempts, child abuse, exposure to violence/aggression, combat) Habituation functions to lower the fear of death AND

ALSO elevate tolerance for pain (A lethal or near-lethal suicide attempt is fear-inducing and often pain-inducing, therefore, habituation to the fear/pain involved is a prerequisite for serious suicidal behavior) Capability develops as a function of repeated exposure to painful stimuli, through which the individual habituates to previously aversive stimuli Interpersonal Theory of Suicide Those Who Desire Suicide Perceived

Burdensomeness Those Who Are Capable of Suicide Habituation to painful stimuli (e.g., combat exposure) Thwarted Belongingness

Serious Attempt or Death by Suicide Joiner, 2005 The Role of Combat Exposure Exposure to painful and provocative experiences such as combat contribute to fearlessness about death and increased pain tolerance, which serve to enhance the individuals capability to attempt suicide Violent and aggressive combat experiences, in particular, should demonstrate relatively stronger associations to this capability. In a sample of deployed active duty combatants, combat

characterized by violence and high levels of injury were associated with relatively stronger associations of the acquired capability for suicide Craig et al, 2011 Not all combat experiences are equal Level of violence Firefights vs. nonhostile, routine patrols Proximity Hand-to-hand combat vs. artillery fire at a distance

Personal responsibility Killing an enemy combatant vs. witnessing others engaged in combat Craig et al, 2011 Combat experiences are influenced by: Occupation Medics vs. infantrymen Location of deployment Relatively well-controlled areas vs hostile areas

with high combat operations Craig et al, 2011 Additionally Combat experiences marked by initiation of violence toward others (e.g., firing upon the enemy) are more strongly associated with suicide attempts than combat experiences without active initiation of violence. Fontana et al, 1992

What does all this mean? Viewed from the perspective of Joiners theory, the findings regarding violent and aggressive combat experiences could be explained by differing levels of acquired ability (i.e., fearlessness about death and pain tolerance) associated with these different types of combat. Interpersonal Theory of Suicide Those Who Desire Suicide Perceived

Burdensomeness Acquired Ability (e.g., violent combat exposure) Thwarted Belongingness Serious Attempt or Death by Suicide Joiner, 2005 Treatment Implications Joiners model posits that prevention of acquired ability OR of burdensomeness

OR of thwarted belongingness will mitigate serious suicidality. Belongingness may be the most malleable and most powerful. Suicide Risk Assessment We assess risk to Take good care of our patients and to guide our interventions The purpose of systematic suicide risk assessment is to identify modifiable and treatable risk factors that inform the patients overall

treatment and management requirements (Simon 2001) Fortunately, the best way to care for our potential suicidal patients and ourselves are one in the same (Simon 2006) Shock, Disbelief, Denial, Grief, Shame, Anger, and FEAR Clinically Based Risk Management Clinically based risk management is patient centered

Supports treatment process and therapeutic alliance Good clinical care = best risk management Simon 2006 Suicide Risk Assessment Refers to the establishment of a clinical judgment of risk in the near future, based on the weighing of a very large amount of available clinical detail.

Good Clinical Practice is the Best Medicine Evaluation Accurate diagnosis Systematic suicide risk assessment Get/review prior treatment records Treatment Formulate, document, and implement a cogent treatment plan Continually assess risk Management Safety management (hospitalize, safety plans, precautions, etc) Communicate and enlist support of others for patients suicide crisis

Never worry alone. (Gutheil 2002) Suicide Risk Assessment No standard of care for the prediction of suicide Suicide is a rare event Efforts at prediction yield lots of false-positives as well as some false-negatives Structured scales may augment, but do not replace systematic risk assessment Actuarial analysis does not reveal specific treatable risk factors or modifiable protective factors for individual patients

Suicide Risk Assessment Standard of care does require suicide risk assessment whenever indicated Best assessments will attend to both risk and protective factors Risk assessment is not an event, it is a process Inductive process to generate specific patient data to guide clinical judgment, treatment, and management Research identifying risk and protective factors enables evidence-based treatment and safety management decision making

APA Practice Guideline for the Assessment and Treatment of Patients with Suicidal Behaviors Toc_14.aspx Quick Reference Guide Indications Risk/protective factors Helpful questions to uncover suicidality And more Important Domains of a Suicide- Focused Psychiatric Interview

Psychiatric Illness History Psychosocial situation Individual strengths and vulnerabilities Current presentation of suicidality Specifically inquire about suicidal thoughts, plans and behaviors

Thorough Psychiatric Evaluation Identify psychiatric signs and symptoms In particular, sxs that might influence risk: aggression, violence, impulsivity, insomnia, hopelessness, etc. Assess past suicidal and self-injurious behavior For each attempt document details: precipitant, timing, intent, consequences, and medical severity Substances involved? Investigate pts thoughts about attempt: perception of lethality, ambivalence about living, degree of premeditation, rehearsal Review past treatment history and relationships

Gauge strength of therapeutic alliance Thorough Psychiatric Evaluation Indentify family history of suicide, mental illness, and dysfunction Investigate current psychosocial situation and nature of any current crisis Acute crisis or chronic stressors may augment risk: financial, legal, interpersonal conflict or loss, housing, employment, etc. Investigate strengths! Coping skills, personality traits, thinking style,

supportive relationships, etc Specific Inquiry of Thoughts, Plans, and Behaviors Elicit any suicidal ideation Focus on nature, frequency, extent, timing Assess feelings about living Presence or Absence of Plan What are plans, what steps have been taken Investigate patients belief regarding lethality Ask what circumstances might lead them to enact plan

Ask about GUNS and address the issue Specific Inquiry of Thoughts, Plans, and Behaviors Assess patients degree of suicidality, including intent and lethality of the plan Consider motivations, seriousness and extent of desire to die, associated behaviors and plans, lethality of method, feasibility Realize that suicide assessment scales have low predictive values Strive to know your patient and their specific

or idiosyncratic warning signs Identify Suicide Risk Factors Specific factors that may generally increase risk for suicide or other self-directed violent behaviors A major focus of research for past 30 years Categories of risk factors Demographic Psychiatric Psychosocial stressors Past history

Warning Signs Warning signs person-specific emotions, thoughts, or behaviors precipitating suicidal behavior Proximal to the suicidal behavior and imply imminent risk The presence of suicide warning signs, especially when combined with suicide risk factors generates the need to conduct further suicide risk assessment Risk Factors vs. Warning Signs Characteristic Feature

Risk Factor Warning Sign Relationship to Suicide Distal Proximal Empirical Support derived

Timeframe EvidenceEnduring Nature of Occurrence Clinically base Imminent Relatively stable

Implications for Clinical Practice At times limited intervention Transient Demands Risk Factors vs. Warning Signs Risk Factors Suicidal ideas/behaviors Psychiatric diagnoses Physical illness Childhood trauma

Genetic/family effects Psychological features (i.e. hopelessness) Cognitive features Demographic features Access to means Substance intoxication Poor therapeutic relationship Warning Signs Threatening to hurt or kill self or talking of wanting to hurt or kill him/herself

Seeking access to lethal means Talking or writing about death, dying or suicide Increased substance (alcohol or drug) use No reason for living; no sense of purpose in life Feeling trapped - like theres no way out Anxiety, agitation, unable to sleep Hopelessness Withdrawal, isolation

Determine if factors are modifiable Non-modifiable Risk Factors Modifiable Risk Factors Family History Treat psychiatric symptoms Past history Increase social support Demographics Remove access to lethal means Dont Neglect Modifiable Protective Factors These are often key to addressing long-term

or chronic risk Sense of responsibility to family Reality testing ability Positive coping skills Positive problem-solving skills Enhanced social support Positive therapeutic relationships Establish Diagnosis and Risk Axis I, II, III, and IV all extremely pertinent to informed determination of risk In estimating risk, combine all elements: Psychiatric illness

Medical illness Acute stressors Risk factors and patient-specific warning signs Protective factors Nature, intensity, frequency of suicidal thoughts, plans, and behaviors Veteran specific considerations (i.e., combat exposure, agent of killing) Acute v. Chronic Risk These are very different, and each carry there own specific treatment/safety A 29 y/o female with hx of 18 suicide attempts and

chronic suicidal ideation, numerous psychiatric admissions, family hx of suicide, gun ownership, TBI, intermittent homelessness, alcohol dependence, and BPD presents to ER with c/o SOB; asked to conduct psychiatric evaluation given her well-known history. What is her risk? Formulation and plan for such individuals necessitates separate consideration of chronic and acute risk Acute v. Chronic Risk Acute and chronic risk are dissociable Document estimation for each Although patient carries many static risk

factors placing her at high chronic risk for engaging in suicidal behaviors, her present mood, stable housing, sustained sobriety, and SI below baseline suggest little acute/imminent risk for suicidal behavior. Psychiatric Management Establish/Maintain therapeutic alliance Taking responsibility for patients care is not the same as taking responsibility for the patients life Attend to safety and determine treatment setting

Level of observation, frequency of sessions Restricting access to means Consider safety needs, optimal treatment setting, and patient's ability to benefit from such Develop a Treatment Plan For the suicidal patient, particular attention should be paid to modifiable risk and protective factors Static risk factors help stratify level of risk, but are typically of little use in treatment; cant change age, gender, or history Modifiable risk factors are typically many: medical illness (pain), psychiatric symptoms (psychosis), active

substance abuse, cognitive styles, access to means, etc Augment protective factors (i.e. enhance sense of belonging) References

Jakupcak M, Hoerster KD, Varra A, Vannoy S, Felker B, Hunt S. Hopelessness and suicidal ideation in Iraq and Afghanistan War Veterans reporting subthreshold and threshold posttraumatic stress disorder. J Nerv Ment Dis 2011;199:272275. Tarrier N, Gregg L. Suicide risk in civilian PTSD patientspredictors of suicidalideation, planning and attempts. Soc Psychiatry Psychiatr Epidemiol 2004; 39:655661. Bell JB, Nye EC. Specific symptoms predict suicidal ideation in Vietnam combat veterans with chronic post-traumatic stress disorder. Mil Med 2007; 172:11441147. Kramer TL, Lindy JD, Green BL, Grace MC, Leonard AC. The comorbidity of post-traumatic stress disorder and suicidality in Vietnam veterans. Suicide Life Threat Behav 1994; 24:5867. Ferrada-Noli M, Asberg M, Ormstad K. Suicidal behavior after severe trauma. Part 2: The association between methods of torture and of suicidal ideation in posttraumatic stress disorder. J Trauma Stress 1998; 11:113124. Tiet QQ, Finney JW, Moos RH. Recent sexual abuse, physical abuse, and suicide attempts among male veterans seeking

psychiatric treatment. Psychiatr Serv 2006; 57:107113. CRAIG J. BRYAN, PSYD, ABPP, AND KELLY C. CUKROWICZ, PHD. Associations Between Types of Combat Violence and the Acquired Capability for Suicide. Suicide and Life-Threatening Behavior 41(2) April 2011 FONTANA, A., ROSENHECK, R., & BRETT, E. (1992). War zone traumas and posttraumatic stress disorder symptomatology. The Journal of Nervous and Mental Disease, 180, 748755. Pietrzak RH, Goldstein MB, Malley JC, Rivers AJ, Johnson DC, Southwick SM. Risk and protective factors associated with suicidal ideation in veterans of Operations Enduring Freedom and Iraqi Freedom. J Affect Disord. 2010;123(1-3):102-107. VA National Initiatives that Address the Risk of Suicide Annual depression and PTSD screens Suicide Prevention Coordinators and teams Veterans Crisis Line

VA Crisis Line (1-800-273-TALK) Online chat ( Text option (838255) VA ACE Cards Resources for family members VA Safety Planning Manual Hubs of expertise in suicide prevention (VISNs 2 and 19)

VA ACE Cards These are wallet-sized, easily-accessible, and portable tools on which the steps for being an active and valuable participant in suicide prevention are summarized The accompanying

brochure discusses warning signs of suicide, and provides safety guidelines for each step Resources for Family Members Information and Support After a Suicide Attempt: A Department of Veterans Affairs Resource Guide for Family Members of Veterans Who are Coping with Suicidality This is an online resource that provides sources of information and

support to Veterans, their family members, and their care providers. Resources for Family Members How to Talk to a 9-13 Year-Old Child about a Suicide Attempt in Your Family This information sheet is intended to serve as a guide for adults to use when talking with a 9-13 year-old child about a suicide attempt in the family. It is not intended to replace the advice of a mental health professional. In fact, it may be best to use this along with professional support if you or your child is struggling with how to talk about this difficult topic. It is important to consider your childs level of development and ability to understand events when deciding how to talk with them about this issue. Why should I talk to my child about a suicide attempt in the family? It is important to talk to your child about the suicide attempt to help them understand what has happened. Without

support of friends/family, they may try to make sense of this confusing situation themselves. Sometimes children blame themselves for something they may or may not have done. Children ages 9-13 may not want to talk directly about their worries or feelings. Instead, they may express fears, have trouble sleeping, or become anxious when separated from certain adults. How should I talk to my child?

Keep your childs daily routine as consistent and predictable as possible, but be flexible. Pick a place that is private where your child will feel free to talk. Be aware of what they may overhear from other conversations. Keep it simple. Use words your child will understand and avoid too many details. Ask them questions. Be aware of your own feelings and how you are coming across. For example, your child could mistake an angry tone of voice to mean that you are angry with them or with the family member who attempted suicide. If your family member is in the hospital, talk to your child as soon as possible. Keep checking in with your child. This will help to send the message that you are open to answering questions over time. Be honest. Get other support people involved (friends, clergy). This will benefit you and your child. Offer extra support, affection, and attention during this time (hugs, time together). What do I say to my child?

Start with their understanding of the situation. I want to talk to you about what happened to dad. What do you remember from last night? Describe what has happened using understandable language. Mom was feeling very sad and hurt herself. Inform children about emotional struggles. Grandpa has been feeling very sad lately. Address guilt, blame, shame, and responsibility. I want you to know that this is not your fault. Assure children that their family member is getting treatment/care. Dad is in the hospital getting help. Let them know that their daily routine will stay the same. Even though it is different that mom is not here, you will still go to school tomorrow. Encourage them to express their feelings. Help them to know that their reactions are normal and expected. Ask if they have questions. I wonder what you are thinking about the things Ive told you. Sometimes kids feel like it is

their fault, or they did something wrong or that it will happen to them or other adults in their life. Do you feel any of these? Sometimes it is easier to draw or write about feelings than say them. Would you like to draw a picture of your feelings? Do you have any questions about grandpa and what happened?" Help create a connection between the child and their family member. Tell them when they can expect to see their family member again. Would you like to draw a picture for or write a letter to dad while hes in the hospital? He will be there for a few days. Allow them not to talk if they desire, and to choose who they talk to. Discuss how your child can share this information with family and friends. If you dont want to talk about it now, thats ok. We can talk about it later or you can talk to grandma, too. Would you like to talk about this with your friend Jane? What would you like her to know? Let them know you are getting support, too. This is something that makes me sad and I need to get some help, too (from clergy, friends, and/or my doctor). Reassure them that you are in charge and in control, and that they can come to you with concerns and questions.

Consider suggesting a special activity to keep them busy, active, or involved with a familiar project; however, it is important not to encourage ongoing distraction or avoidance of feelings. Guidelines for talking to children (4-8 years, 9-13 years, 14-18 years) about a family member's suicide attempt These guides provide an outline of how and what to say to children about the topic of suicide. VISN 19 MIRECC Website Research Education Clinical Care Assessment Tools Fellowship Info Personnel Presentations Study Participation Contact Us New Service for VA Providers

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