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Cognitive Therapy and Research

, Volume 42, Issue 5, pp 711–719 | Cite as

Posttraumatic Cognitions and Suicidal Ideation Among Veterans Receiving PTSD Treatment

  • Adam G. Horwitz
  • Philip Held
  • Brian J. Klassen
  • Niranjan S. Karnik
  • Mark H. Pollack
  • Alyson K. Zalta
Original Article

Abstract

With approximately 20 veteran suicide deaths per day, suicidal ideation (SI) among veterans is an important concern. Posttraumatic stress disorder (PTSD) is associated with SI among veterans, yet mechanisms of this relationship remain unclear. Negative posttraumatic cognitions contribute to the development and maintenance of PTSD, yet no studies have prospectively examined the relationship between posttraumatic cognitions and SI. Veterans (N = 177; 66% Male) participating in a 3-week intensive outpatient program for PTSD completed assessments of PTSD severity, depressive symptoms, SI, and posttraumatic cognitions. Negative posttraumatic cognitions about the self significantly predicted SI at posttreatment, controlling for pretreatment levels of SI, depression, and PTSD symptom severity. Self-blame and negative posttraumatic cognitions about others/world did not predict SI prospectively. Negative posttraumatic cognitions about the self appear to be an important factor in the manifestation of SI among veterans with PTSD and should be monitored as a potential indicator of suicide risk.

Keywords

PTSD Suicidal ideation Posttraumatic cognitions Veterans 

Notes

Acknowledgements

We thank the Wounded Warrior Project for their support of the Warrior Care Network and the resulting research. We would also like to thank the participating veterans and their families. We also wish to acknowledge the administrators, research assistants, and clinicians in the Road Home Program.

Compliance with Ethical Standards

Conflict of Interest

Philip Held receives grant support from the Boeing Company and the American Psychological Association. Niranjan Karnik receives grant support from the Wounded Warrior Project; Welcome Back Veterans, an initiative of the McCormick Foundation and Major League Baseball; and the National Center for Advancing Translational Science of the National Institutes of Health (UL1TR002389). Mark Pollack receives funding from the Wounded Warrior Project, National Institute of Health, and Janssen Pharmaceuticals. Dr. Pollack serves on advisory boards for Aptinyx, Bracket Global, Palo Alto Health Sciences and has equity from Doyen Medical, Argus, Medavante, Mensante Corporation, Mindsite, and Targia Pharmaceuticals and receives royalties from SIGH-A, SAFER interviews. Alyson Zalta is supported by a career development award from the National Institute of Mental Health (K23 MH103394).

Informed Consent

All study procedures were approved by the Institutional Review Board with a waiver of consent because all assessments were collected as part of routine clinical care procedures.

Animal rights

No animal studies were carried out by the authors for this article.

References

  1. Beck, A. T., Brown, G. K., Steer, R. A., Dahlsgaard, K. K., & Grisham, J. R. (1999). Suicide ideation at its worst point: A predictor of eventual suicide in psychiatric outpatients. Suicide & Life-Threatening Behavior, 29(1), 1–9.  https://doi.org/10.1111/j.1943-278X.1999.tb00758.x.CrossRefGoogle Scholar
  2. Black, S. A., Gallaway, M. S., Bell, R., & Ritchie, E. C. (2011). Prevalence and risk factors associated with suicides of army soldiers 2001–2009. Military Psychology, 23(4), 433–451.  https://doi.org/10.1080/08995605.2011.590409.CrossRefGoogle Scholar
  3. Bovin, M. J., Marx, B. P., Weathers, F. W., Gallagher, M. W., Rodriguez, P., Schnurr, P. P., & Keane, T. M. (2016). Psychometric properties of the PTSD checklist for diagnostic and statistical manual of mental disorders–fifth edition (PCL-5) in veterans. Psychological Assessment, 28(11), 1379–1391.  https://doi.org/10.1037/pas0000254.CrossRefPubMedGoogle Scholar
  4. Brewin, C. R., & Holmes, E. A. (2003). Psychological theories of posttraumatic stress disorder. Clinical Psychology Review, 23(3), 339–376.  https://doi.org/10.1016/S0272-7358(03)00033-3.CrossRefPubMedGoogle Scholar
  5. Brown, G. K., Beck, A. T., Steer, R. A., & Grisham, J. R. (2000). Risk factors for suicide in psychiatric outpatients: A 20-year prospective study. Journal of Consulting and Clinical Psychology, 68(3), 371–377.  https://doi.org/10.1037//0022-006X.68.3.371.CrossRefPubMedGoogle Scholar
  6. Centers for Disease Control and Prevention. (2017). Web-based injury statistics query and reporting system (WISQARS). Retrieved December 6, 2017, from http://www.cdc.gov/injury/wisqars/index.html.
  7. Cox, K. S., Mouilso, E. R., Venners, M. R., Defever, M. E., Duvivier, L., Rauch, S. A. M., … Tuerk, P. W. (2016). Reducing suicidal ideation through evidence-based treatment for posttraumatic stress disorder. Journal of Psychiatric Research, 80, 59–63.  https://doi.org/10.1016/j.jpsychires.2016.05.011.CrossRefPubMedGoogle Scholar
  8. Dalgleish, T. (2004). Cognitive approaches to posttraumatic stress disorder: The evolution of multirepresentational theorizing. Psychological Bulletin, 130(2), 228–260.  https://doi.org/10.1037/0033-2909.130.2.228.CrossRefPubMedGoogle Scholar
  9. Department of Veterans Affairs. (2016). Suicide among veterans and other Americans 2001–2014. Washington, DC: Office of Suicide Prevention.Google Scholar
  10. Ehlers, A., & Clark, D. M. (2000). A cognitive model of posttraumatic stress disorder. Behavior Research and Therapy, 38, 319–345.  https://doi.org/10.1016/S0005-7967(99)00123-0.CrossRefGoogle Scholar
  11. Foa, E. B., Ehlers, A., Clark, D. M., Tolin, D. F., & Orsillo, S. M. (1999). The posttraumatic cognitions inventory (PTCI): Development and validation. Psychological Assessment, 11(3), 303–314.  https://doi.org/10.1037/1040-3590.11.3.303.CrossRefGoogle Scholar
  12. Foa, E. B., & Rauch, S. A. M. (2004). Cognitive changes during prolonged exposure versus prolonged exposure plus cognitive restructuring in female assault survivors with posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 72(5), 879–884.  https://doi.org/10.1037/0022-006X.72.5.879.CrossRefPubMedGoogle Scholar
  13. Fulton, J. J., Calhoun, P. S., Wagner, H. R., Schry, A. R., Hair, L. P., Feeling, N., … Beckham, J. C. (2015). The prevalence of posttraumatic stress disorder in Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans: A meta-analysis. Journal of Anxiety Disorders, 31, 98–107.  https://doi.org/10.1016/j.janxdis.2015.02.003.CrossRefPubMedGoogle Scholar
  14. Gallagher, M. W., & Resick, P. A. (2012). Mechanisms of change in cognitive processing therapy and prolonged exposure therapy for ptsd: Preliminary evidence for the differential effects of hopelessness and habituation. Cognitive Therapy and Research, 36(6), 750–755.  https://doi.org/10.1007/s10608-011-9423-6.CrossRefGoogle Scholar
  15. Gradus, J. L., Suvak, M. K., Wisco, B. E., Marx, B. P., & Resick, P. A. (2013). Treatment of posttraumatic stress disorder reduces suicidal ideation. Depression and Anxiety, 30(10), 1046–1053.  https://doi.org/10.1002/da.22117.PubMedCrossRefGoogle Scholar
  16. Harvey, M. M., Rauch, S. A., Zalta, A. K., Sornborger, J., Pollack, M. H., Rothbaum, B. O., … Simon, N. M. (2017). Intensive treatment models to address posttraumatic stress among post-9/11 warriors: The Warrior Care Network. Focus, 15(4), 378–383.CrossRefGoogle Scholar
  17. Horwitz, A. G., Berona, J., Czyz, E. K., Yeguez, C. E., & King, C. A. (2017). Positive and negative expectations of hopelessness as longitudinal predictors of depression, suicidal ideation, and suicidal behavior in high-risk adolescents. Suicide and Life-Threatening Behavior, 47, 168–176.  https://doi.org/10.1111/sltb.12273.CrossRefPubMedGoogle Scholar
  18. Horwitz, A. G., Czyz, E. K., Berona, J., & King, C. A. (2018). Prospective associations of coping styles with depression and suicide risk among psychiatric emergency patients. Behavior Therapy, 39, 225–236.CrossRefGoogle Scholar
  19. Horwitz, A. G., Miron, L., & Maieritsch, K. P. (2019). Prospective associations between DSM-5 PTSD symptom clusters and suicidal ideation in treatment seeking veterans. Psychological Services.Google Scholar
  20. Jakupcak, M., Cook, J., Imel, Z., Fontana, A., Rosenheck, R., & McFall, M. (2009). Posttraumatic stress disorder as a risk factor for suicidal ideation in Iraq and Afghanistan war veterans. Journal of Traumatic Stress, 22(4), 303–306.  https://doi.org/10.1002/jts.20423.CrossRefPubMedGoogle Scholar
  21. Kabat-Zinn, J. (2003). Mindfulness-based stress reduction (MBSR). Constructivism in the Human Sciences, 8(2), 73–107.Google Scholar
  22. Kang, H. K., Natelson, B. H., Mahan, C. M., Lee, K. Y., & Murphy, F. M. (2003). Post-traumatic stress disorder and chronic fatigue syndrome-like illness among gulf war veterans: A population-based survey of 30,000 veterans. American Journal of Epidemiology, 157(2), 141–148.  https://doi.org/10.1093/aje/kwf187.CrossRefPubMedGoogle Scholar
  23. Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R., & Walters, E. E. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62(6), 593–602.  https://doi.org/10.1001/archpsyc.62.6.593.CrossRefPubMedGoogle Scholar
  24. Kessler, R. C., Sonnega, A., Bromet, E., Hughes, M., Nelson, C. B., & Bromet, E. (1995). Posttraumatic stress disorder in the National Comorbidity Survey. Archives of General Psychiatry, 52(12), 1048–1060.  https://doi.org/10.1001/archpsyc.1995.03950240066012.CrossRefPubMedGoogle Scholar
  25. Kroenke, K., Spitzer, R. L., & Williams, J. B. W. (2001). The PHQ-9. Journal of General Internal Medicine, 16(9), 606–613.  https://doi.org/10.1046/j.1525-1497.2001.016009606.x.CrossRefPubMedPubMedCentralGoogle Scholar
  26. Kroenke, K., Strine, T. W., Spitzer, R. L., Williams, J. B. W., Berry, J. T., & Mokdad, A. H. (2009). The PHQ-8 as a measure of current depression in the general population. Journal of Affective Disorders, 114(1), 163–173.CrossRefPubMedGoogle Scholar
  27. Krysinska, K., & Lester, D. (2010). Post-traumatic stress disorder and suicide risk: A systematic review. Archives of Suicide Research, 14(1), 1–23.  https://doi.org/10.1080/13811110903478997.CrossRefPubMedGoogle Scholar
  28. Kulka, R. A., Schlenger, W. E., Fairbank, J. A., Hough, R. L., Jordan, B. K., Marmar, C. R., & Weiss, D. S. (1990). Trauma and the Vietnam war generation: Report of findings from the National Vietnam Veterans Readjustment Study. Philadelphia, PA: Brunner/Mazel.Google Scholar
  29. Maguen, S., Luxton, D. D., Skopp, N. A., Gahm, G. A., Reger, M. A., Metzler, T. J., & Marmar, C. R. (2011). Killing in combat, mental health symptoms, and suicidal ideation in Iraq war veterans. Journal of Anxiety Disorders, 25(4), 563–567.CrossRefPubMedGoogle Scholar
  30. McLean, C. P., Zang, Y., Zandberg, L., Bryan, C. J., Gay, N., Yarvis, J. S., & Foa, E. B. (2017). Predictors of suicidal ideation among active duty military personnel with posttraumatic stress disorder. Journal of Affective Disorders, 208, 392–398.  https://doi.org/10.1016/j.jad.2016.08.061.CrossRefPubMedGoogle Scholar
  31. Miranda, R., & Nolen-Hoeksema, S. (2007). Brooding and reflection: Rumination predicts suicidal ideation at 1-year follow-up in a community sample. Behaviour Research and Therapy, 45(12), 3088–3095.  https://doi.org/10.1016/j.brat.2007.07.015.CrossRefPubMedPubMedCentralGoogle Scholar
  32. Nock, M. K., Borges, G., Bromet, E. J., Alonso, J., Angermeyer, M., Beautrais, A., … Williams, D. (2008). Cross-national prevalence and risk factors for suicidal ideation, plans and attempts. British Journal of Psychiatry, 192(2), 98–105.  https://doi.org/10.1192/bjp.bp.107.040113.CrossRefPubMedGoogle Scholar
  33. Norris, F. H., & Slone, L. B. (2007). The epidemiology of trauma and PTSD. In Handbook of PTSD: Science and practice (pp. 78–98). New York, NY: Guilford Press.Google Scholar
  34. Panagioti, M., Gooding, P. A., & Tarrier, N. (2012). A meta-analysis of the association between posttraumatic stress disorder and suicidality: The role of comorbid depression. Comprehensive Psychiatry, 53(7), 915–930.  https://doi.org/10.1016/j.comppsych.2012.02.009.CrossRefPubMedGoogle Scholar
  35. Pietrzak, R. H., Goldstein, M. B., Malley, J. C., Rivers, A. J., Johnson, D. C., & Southwick, S. M. (2010). Risk and protective factors associated with suicidal ideation in veterans of Operations Enduring Freedom and Iraqi Freedom. Journal of Affective Disorders, 123(1–3), 102–107.  https://doi.org/10.1016/j.jad.2009.08.001.CrossRefPubMedGoogle Scholar
  36. Resick, P. A., Monson, C. M., & Chard, K. M. (2016). Cognitive processing therapy for PTSD: A comprehensive manual. New York, NY: Guilford Press.Google Scholar
  37. Rogers, M. L., & Joiner, T. E. (2017). Rumination, suicidal ideation, and suicide attempts: A meta-analytic review. Review of General Psychology, 21(2), 132–142.  https://doi.org/10.1037/gpr0000101.CrossRefGoogle Scholar
  38. Rudd, D. M., Berman, A. L., Joiner, T. E., Nock, M. K., Silverman, M. M., Mandrusiak, M., … Witte, T. (2006). Warning signs for suicide: Theory, research, and clinical applications. Suicide and Life-Threatening Behavior, 36(3), 255–262.  https://doi.org/10.1521/suli.2006.36.3.255.CrossRefPubMedGoogle Scholar
  39. Scher, C. D., Suvak, M. K., & Resick, P. A. (2017). Trauma cognitions are related to symptoms up to 10 years after cognitive behavioral treatment for posttraumatic stress disorder. Psychological Trauma: Theory, Research, Practice, and Policy, 9(6), 750–757.  https://doi.org/10.1037/tra0000258.CrossRefGoogle Scholar
  40. Schumm, J., Dickstein, B. D., Walter, K. H., Owens, G. P., & Chard, K. M. (2015). Changes in posttraumatic cognitions predict changes in posttraumatic stress disorder symptoms during cognitive processing therapy. Journal of Consulting and Clinical Psychology, 83(6), 1161–1166.  https://doi.org/10.1037/ccp0000040.CrossRefPubMedGoogle Scholar
  41. Simon, G. E., Rutter, C. M., Peterson, D., Oliver, M., Whiteside, U., Operskalski, B., & Ludman, E. J. (2013). Does response on the PHQ-9 depression questionnaire predict subsequent suicide attempt or suicide death? Psychiatric Services, 64(12), 1195–1202.CrossRefPubMedGoogle Scholar
  42. Smith, N. B., Mota, N., Tsai, J., Monteith, L., Harpaz-Rotem, I., Southwick, S. M., & Pietrzak, R. H. (2016). Nature and determinants of suicidal ideation among U.S. veterans: Results from the national health and resilience in veterans study. Journal of Affective Disorders, 197, 66–73.  https://doi.org/10.1016/j.jad.2016.02.069.CrossRefPubMedGoogle Scholar
  43. Ten Have, M., De Graaf, R., Van Dorsselaer, S., Verdurmen, J., Van’t Land, H., Vollebergh, W., & Beekman, A. (2009). Incidence and course of suicidal ideation and suicide attempts in the general population. Canadian Journal of Psychiatry, 54(12), 824–833.CrossRefPubMedGoogle Scholar
  44. Van Orden, K. A., Witte, T. K., Cukrowicz, K. C., Braithwaite, S. R., Selby, E. A., & Joiner, T. E. (2010). The interpersonal theory of suicide. Psychological Review, 117(2), 575–600.  https://doi.org/10.1037/a0018697.CrossRefPubMedPubMedCentralGoogle Scholar
  45. Weathers, F. W., Bovin, M. J., Lee, D. J., Sloan, D. M., Schnurr, P. P., Kaloupek, D. G., … Marx, B. P. (2017). The Clinician-Administered PTSD Scale for DSM–5 (CAPS-5): Development and initial psychometric evaluation in military veterans. Psychological Assessment.  https://doi.org/10.1037/pas0000486.PubMedCrossRefGoogle Scholar
  46. Weathers, F. W., Litz, B. T., Keane, T. M., Palmieri, P. A., Marx, B. P., & Schnurr, P. P. (2013). The PTSD checklist for DSM-5 (PCL-5). National Center for PTSD.  https://doi.org/10.1037/t02622-000.CrossRefGoogle Scholar
  47. Wells, T. S., Horton, J. L., LeardMann, C. A., Jacobson, I. G., & Boyko, E. J. (2013). A comparison of the PRIME-MD PHQ-9 and PHQ-8 in a large military prospective study, the Millennium Cohort Study. Journal of Affective Disorders, 148(1), 77–83.CrossRefPubMedGoogle Scholar
  48. Wenzel, A., & Beck, A. T. (2008). A cognitive model of suicidal behavior: Theory and treatment. Applied and Preventive Psychology, 12(4), 189–201.  https://doi.org/10.1016/j.appsy.2008.05.001.CrossRefGoogle Scholar
  49. Zalta, A. K., Gillihan, S. J., Fisher, A. J., Mintz, J., McLean, C. P., Yehuda, R., & Foa, E. B. (2014). Change in negative cognitions associated with PTSD predicts symptom reduction in prolonged exposure. Journal of Consulting and Clinical Psychology, 82(1), 171–175.  https://doi.org/10.1037/a0034735.CrossRefPubMedGoogle Scholar
  50. Zalta, A. K., Held, P., Smith, D. L., Klassen, B. J., Lofgreen, A. M., Normand, P. S., … Karnik, N. S. (under review). Evaluating patterns and predictors of symptom change during a three-week intensive outpatient treatment for veterans with PTSD.Google Scholar

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© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of PsychiatryRush University Medical CenterChicagoUSA
  2. 2.Department of Behavioral SciencesRush University Medical CenterChicagoUSA

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