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Treating PTSD Within the Context of Heightened Suicide Risk

  • Disaster Psychiatry: Trauma, PTSD, and Related Disorders (E Foa and A Asnaani, Section Editors)
  • Published:
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Abstract

Because posttraumatic stress disorder (PTSD) is one of the few psychological conditions that predict suicidal behavior among those who think about suicide, many patients with PTSD present clinically with elevated suicide risk. Expert consensus and practice guidelines recommend against trauma-focused treatments for patients with elevated suicide risk, however. Research aimed at understanding the common mechanisms that underlie the association of PTSD and suicide risk has led to several advances in the effective care of suicidal patients diagnosed with PTSD. Based on these results, various combinations and sequences of suicide-focused treatments, risk management procedures, and trauma-focused treatments are implicated.

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Notes

  1. Preparatory behaviors refer to steps taken by the individual to prepare for a suicide attempt (e.g., writing a suicide note, visiting the location of the planned attempt, purchasing a weapon, and hoarding or counting pills). Rehearsal behaviors refer to “practicing” or completing a “dry run” of the suicide attempt. Preparatory and rehearsal behaviors are especially high-risk indicators of imminent suicidal behavior.

References

Papers of particular interest, published recently, have been highlighted as:•• Of major importance

  1. Panagioti M, Gooding P, Tarrier N. Post-traumatic stress disorder and suicidal behavior: a narrative review. Clin Psychol Rev. 2009;29(6):471–82.

    Article  PubMed  Google Scholar 

  2. Nock MK, Hwang I, Sampson N, Kessler RC, Angermeyer M, Beautrais A, et al. Cross-national analysis of the associations among mental disorders and suicidal behavior: findings from the WHO World Mental Health Surveys. PLoS Med. 2009;6(8):e1000123. doi:10.1371/journal.pmed.1000123.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Bernal M, Haro JM, Bernert S, Brugha T, de Graaf R, Bruffaerts R, et al. Risk factors for suicidality in Europe: results from the ESEMED Study. J Affect Disord. 2007;101(1):27–34.

    Article  CAS  PubMed  Google Scholar 

  4. Guerra VS, Calhoun PS. Examining the relation between posttraumatic stress disorder and suicidal ideation in an OEF/OIF veteran sample. J Anxiety Disord. 2011;25(1):12–8.

    Article  PubMed  Google Scholar 

  5. Gradus JL, Qin P, Lincoln AK, Miller M, Lawler E, Sørensen HT, et al. Posttraumatic stress disorder and completed suicide. Am J Epidemiol. 2010;171(6):721–7.

    Article  PubMed  Google Scholar 

  6. Oquendo MA, Friend JM, Halberstam B, Brodsky BS, Burke AK, Grunebaum MF et al. Association of comorbid posttraumatic stress disorder and major depression with greater risk for suicidal behavior. Am J Psychiatry. 2003;160:580–2.

  7. Rudd MD, Goulding J, Bryan CJ. Student veterans: a national survey exploring psychological symptoms and suicide risk. Prof Psychol: Res Pract. 2011;42(5):354.

    Article  Google Scholar 

  8. Bryan CJ, Clemans TA, Hernandez AM, Rudd MD. Loss of consciousness, depression, posttraumatic stress disorder, and suicide risk among deployed military personnel with mild traumatic brain injury. J Head Trauma Rehabil. 2013;28(1):13–20.

    Article  PubMed  Google Scholar 

  9. Marshall RD, Olfson M, Hellman F, Blanco C, Guardino M, Struening EL. Comorbidity, impairment, and suicidality in subthreshold PTSD. Am J Psychiatry. 2001;158:1467–73.

  10. May AM, Klonsky ED. What distinguishes suicide attempters from suicide ideators? A meta‐analysis of potential factors. Clin Psychol: Sci Pract. 2016;23:5–20.

  11. Bell JB, Nye EC. Specific symptoms predict suicidal ideation in Vietnam combat veterans with chronic post-traumatic stress disorder. Mil Med. 2007;172(11):1144–7.

    Article  PubMed  Google Scholar 

  12. Tarrier N, Gregg L. Suicide risk in civilian PTSD patients. Soc Psychiatry Psychiatr Epidemiol. 2004;39(8):655–61.

    Article  PubMed  Google Scholar 

  13. Bryan CJ. PTSD and self-directed violence. In: Martin C, Preedy V, Patel VB, editors. Comprehensive guide to posttraumatic stress disorder. New York: Springer; 2015. p. 1–9.

    Chapter  Google Scholar 

  14. Joiner T. Why people die by suicide. Cambridge, MA: Harvard University Press; 2005.

  15. Linehan M. Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford; 1993.

    Google Scholar 

  16. Rudd MD, Joiner TE, Rajab MH. Treating suicidal behavior: an effective, time-limited approach. New York: Guilford; 2004.

  17. Shneidman ES. Commentary: suicide as psychache. J Nerv Ment Dis. 1993;181(3):145–7.

    Article  CAS  PubMed  Google Scholar 

  18. Bryan CJ, Rudd MD, Wertenberger E. Reasons for suicide attempts in a clinical sample of active duty soldiers. J Affect Disord. 2013;144(1):148–52.

    Article  PubMed  Google Scholar 

  19. Steil R, Dyer A, Priebe K, Kleindienst N, Bohus M. Dialectical behavior therapy for posttraumatic stress disorder related to childhood sexual abuse: a pilot study of an intensive residential treatment program. J Trauma Stress. 2011;24(1):102–6.

    Article  PubMed  Google Scholar 

  20. Bryan AO, Bryan CJ, Morrow CE, Etienne N, Ray-Sannerud B. Moral injury, suicidal ideation, and suicide attempts in a military sample. Traumatology. 2014;20(3):154.

    Article  Google Scholar 

  21. Bryan CJ, Ray-Sannerud B, Morrow CE, Etienne N. Guilt is more strongly associated with suicidal ideation among military personnel with direct combat exposure. J Affect Disord. 2013;148(1):37–41.

    Article  PubMed  Google Scholar 

  22. Bryan CJ, Morrow CE, Etienne N, Ray‐Sannerud B. Guilt, shame, and suicidal ideation in a military outpatient clinical sample. Depression Anxiety. 2013;30(1):55–60.

    Article  PubMed  Google Scholar 

  23. Hendin H, Haas AP. Suicide and guilt as manifestations of PTSD. Am J Psychiatr. 1991;148(5):586–91.

    Article  CAS  PubMed  Google Scholar 

  24. Kubany ES, Haynes SN, Abueg FR, Manke FP, Brennan JM, Stahura C. Development and validation of the Trauma-Related Guilt Inventory (TRGI). Psychol Assess. 1996;8(4):428.

    Article  Google Scholar 

  25. Bryan CJ, Hernandez AM, Allison S, Clemans T. Combat exposure and suicide risk in two samples of military personnel. J Clin Psychol. 2013;69(1):64–77.

    Article  PubMed  Google Scholar 

  26. Bryan C, Roberge E, Bryan A, Ray-Sannerud B. Guilt as a mediator of the relationship among depression and posttraumatic stress with suicide ideation in two samples of military personnel and veterans. Int J Cogn Ther. 2015;8(2):142–54.

    Article  Google Scholar 

  27. Andrews B, Qian M, Valentine JD. Predicting depressive symptoms with a new measure of shame: the Experience of Shame Scale. Br J Clin Psychol. 2002;41(1):29–42.

    Article  PubMed  Google Scholar 

  28. Kim S, Thibodeau R, Jorgensen RS. Shame, guilt, and depressive symptoms: a meta-analytic review. Psychol Bull. 2011;137(1):68.

    Article  PubMed  Google Scholar 

  29. Leskela J, Dieperink M, Thuras P. Shame and posttraumatic stress disorder. J Trauma Stress. 2002;15(3):223–6.

    Article  PubMed  Google Scholar 

  30. 30. Marlatt GA, Donovan DM. Relapse prevention: maintenance strategies in the treatment of addictive behaviors. New York: Guilford; 2005.

  31. Meehan W, O’Connor LE, Berry JW, Weiss J, Acampora A. Guilt, shame, and depression in clients in recovery from addiction. J Psychoactive Drugs. 1996;28(2):125–34.

    Article  CAS  PubMed  Google Scholar 

  32. Rudd MD. Fluid vulnerability theory: a cognitive approach to understanding the process of acute and chronic suicide risk. In: Ellis TE, editor. Cognition and suicide: theory, research, and therapy. Washington, DC: American Psychological Association; 2006. p. 355–68.

    Chapter  Google Scholar 

  33. Bryan CJ, Rudd MD. The importance of temporal dynamics in the transition from suicidal thought to behavior. Clin Psychol Sci Pract. 2016;23(1):21–5. doi:10.1111/cpsp.12135.

    Article  Google Scholar 

  34. Sinclair S, Bryan CJ, Bryan AO. Meaning in life as a protective factor for the emergence of suicide ideation and attempts among military personnel and veterans with elevated PTSD and depression. Int J Cogn Ther. 2016;9:87–98.

  35. Department of Veterans Affairs and Department of Defense. VA/DoD clinical practice guideline for the management of post-traumatic stress disorder. Washington, DC: Department of Veterans Affairs and Department of Defense; 2010.

    Google Scholar 

  36. Forbes D, Creamer M, Phelps A, Bryant R, McFarlane A, Devilly GJ, et al. Australian guidelines for the treatment of adults with acute stress disorder and post-traumatic stress disorder. Aust N Z J Psychiatry. 2007;41(8):637–48.

    Article  PubMed  Google Scholar 

  37. Foa EB, Keane TM, Friedman MJ, Cohen JA. Effective treatments for PTSD: practice guidelines from the International Society for Traumatic Stress Studies. Guilford; 2008.

  38. van Minnen A, Harned MS, Zoellner L, Mills K. Examining potential contraindications for prolonged exposure therapy for PTSD. Eur J Psychotraumatol. 2012;3.

  39. Bryan CJ, Rudd MD. Advances in the assessment of suicide risk. J Clin Psychol. 2006;62(2):185–200.

    Article  PubMed  Google Scholar 

  40. Jacobs D, Baldessarini R, Conwell Y, Fawcett J, Horton L, Meltzer H. Practice guideline for the assessment and treatment of patients with suicidal behaviors. Am J Psychiatry. 2003;160(11 Suppl):1–60.

  41. Mann JJ, Apter A, Bertolote J, Beautrais A, Currier D, Haas A, et al. Suicide prevention strategies: a systematic review. JAMA. 2005;294(16):2064–74.

    Article  CAS  PubMed  Google Scholar 

  42. Covington D, Hogan M, Abreu J, Berman A, Breux P, Coffey E et al. Suicide care in systems framework. National Action Alliance: Clinical Care & Intervention Task Force. 2011. Retrieved 9 January 2013.

  43. National Collaborating Centre for Mental Health, editor. Self-harm: longer-term management. Leicester: British Psychological Society; 2012.

  44. Rathus JH, Miller AL. Dialectical behavior therapy adapted for suicidal adolescents. Suicide Life Threat behav. 2002;32(2):146–57.

    Article  PubMed  Google Scholar 

  45. Linehan MM, Armstrong HE, Suarez A, Allmon D, Heard HL. Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Arch Gen Psychiatry. 1991;48(12):1060–4.

    Article  CAS  PubMed  Google Scholar 

  46. Verheul R, van den Bosch LM, Koeter MW, De Ridder MA, Stijnen T, Van Den Brink W. Dialectical behaviour therapy for women with borderline personality disorder. Br J Psychiatry. 2003;182(2):135–40.

    Article  PubMed  Google Scholar 

  47. Linehan MM, Comtois KA, Murray AM, Brown MZ, Gallop RJ, Heard HL, et al. Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Arch Gen Psychiatry. 2006;63(7):757–66.

    Article  PubMed  Google Scholar 

  48. Brown GK, Ten Have T, Henriques GR, Xie SX, Hollander JE, Beck AT. Cognitive therapy for the prevention of suicide attempts: a randomized controlled trial. JAMA. 2005;294(5):563–70.

    Article  CAS  PubMed  Google Scholar 

  49. Rudd MD, Bryan CJ, Wertenberger EG, Peterson AL, Young-McCaughan S, Mintz J, et al. Brief cognitive-behavioral therapy effects on post-treatment suicide attempts in a military sample: results of a randomized clinical trial with 2-year follow-up. Am J Psychiatr. 2015;172(5):441–9. This randomized controlled trial showed that a 12-session cognitive behavioral treatment reduced suicide attempts by 60 % and led to moderate reductions in PTSD symptom severity.

    Article  PubMed  Google Scholar 

  50. Rudd MD. Brief cognitive behavioral therapy (BCBT) for suicidality in military populations. Mil Psychol. 2012;24(6):592.

    Article  Google Scholar 

  51. Linehan MM, Korslund KE, Harned MS, Gallop RJ, Lungu A, Neacsiu AD, et al. Dialectical behavior therapy for high suicide risk in individuals with borderline personality disorder: a randomized clinical trial and component analysis. JAMA Psychiatry. 2015;72(5):475–82.

    Article  PubMed  Google Scholar 

  52. Wagner AW, Linehan MM. Applications of dialectical behavior therapy to posttraumatic stress disorder and related problems. Cogn Behav Ther Trauma. 2006;2:117–45.

    Google Scholar 

  53. Wagner AW, Rizvi SL, Harned MS. Applications of dialectical behavior therapy to the treatment of complex trauma‐related problems: when one case formulation does not fit all. J Trauma Stress. 2007;20(4):391–400.

    Article  PubMed  Google Scholar 

  54. Harned MS, Korslund KE, Foa EB, Linehan MM. Treating PTSD in suicidal and self-injuring women with borderline personality disorder: development and preliminary evaluation of a Dialectical Behavior Therapy Prolonged Exposure Protocol. Behav Res Ther. 2012;50(6):381–6. doi:10.1016/j.brat.2012.02.011.

    Article  PubMed  PubMed Central  Google Scholar 

  55. Harned MS, Chapman AL, Dexter-Mazza ET, Murray A, Comtois KA, Linehan MM. Treating co-occurring Axis I disorders in recurrently suicidal women with borderline personality disorder: a 2-year randomized trial of dialectical behavior therapy versus community treatment by experts. J Consult Clin Psychol. 2008;76(6):1068.

    Article  PubMed  Google Scholar 

  56. Stanley B, Brown GK. Safety planning intervention: a brief intervention to mitigate suicide risk. Cogn Behav Pract. 2012;19(2):256–64. This paper describes the rationale and components of a crisis response plan (also known as a safety plan).

    Article  Google Scholar 

  57. Rudd MD, Mandrusiak M, Joiner Jr TE. The case against no‐suicide contracts: the commitment to treatment statement as a practice alternative. J Clin Psychol. 2006;62(2):243–51.

    Article  PubMed  Google Scholar 

  58. Bryan CJ. Managing suicide risk in primary care. New York: Springer; 2010.

  59. Institute of Medicine. Treatment of posttraumatic stress disorder: an assessment of the evidence. Washington, DC: National Academies Press; 2008.

  60. Institute of Medicine. Treatment for posttraumatic stress disorder in military and veteran populations: initial assessment. Washington, DC: National Academy Press; 2012.

    Google Scholar 

  61. Resick PA, Williams LF, Suvak MK, Monson CM, Gradus JL. Long-term outcomes of cognitive–behavioral treatments for posttraumatic stress disorder among female rape survivors. J Consult Clin Psychol. 2012;80(2):201.

    Article  PubMed  Google Scholar 

  62. Foa EB, Hembree EA, Cahill SP, Rauch SA, Riggs DS, Feeny NC, et al. Randomized trial of prolonged exposure for posttraumatic stress disorder with and without cognitive restructuring: outcome at academic and community clinics. J Consult Clin Psychol. 2005;73(5):953.

    Article  PubMed  Google Scholar 

  63. Resick PA, Nishith P, Weaver TL, Astin MC, Feuer CA. A comparison of cognitive-processing therapy with prolonged exposure and a waiting condition for the treatment of chronic posttraumatic stress disorder in female rape victims. J Consult Clin Psychol. 2002;70(4):867.

    Article  PubMed  PubMed Central  Google Scholar 

  64. Monson CM, Schnurr PP, Resick PA, Friedman MJ, Young-Xu Y, Stevens SP. Cognitive processing therapy for veterans with military-related posttraumatic stress disorder. J Consult Clin Psychol. 2006;74(5):898.

    Article  PubMed  Google Scholar 

  65. Becker CB, Zayfert C, Anderson E. A survey of psychologists’ attitudes towards and utilization of exposure therapy for PTSD. Behav Res Ther. 2004;42(3):277–92.

    Article  PubMed  Google Scholar 

  66. Bryan CJ, Clemans TA, Hernandez AM, Mintz J, Peterson AL, Yarvis JS, et al. Evaluating potential iatrogenic suicide risk in trauma-focused group cognitive behavioral therapy for the treatment of PTSD in active duty military personnel. Depression Anxiety. 2016;33:549–57. doi:10.1002/da.22456. This secondary analysis of a randomized controlled trial of group cognitive processing therapy and presence-centered therapy found that suicide ideation decreased among military personnel (predominantly male) combat veterans with PTSD.

    Article  PubMed  Google Scholar 

  67. Gradus JL, Suvak MK, Wisco BE, Marx BP, Resick PA. Treatment of posttraumatic stress disorder reduces suicidal ideation. Depression Anxiety. 2013;30(10):1046–53. This secondary analysis of a randomized controlled trial of prolonged exposure and cognitive processing therapy found that suicide ideation decreased among female sexual assault survivors with PTSD.

    PubMed  Google Scholar 

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Authors and Affiliations

  1. National Center for Veterans Studies, The University of Utah, 332 S 1400 E, Room 4, Salt Lake City, UT, 84112, USA

    Craig J. Bryan

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Craig J. Bryan has received grants from the Department of Defense and the National Institute of Drug Abuse.

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This article is part of the Topical Collection on Disaster Psychiatry: Trauma, PTSD, and Related Disorders

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Bryan, C.J. Treating PTSD Within the Context of Heightened Suicide Risk. Curr Psychiatry Rep 18, 73 (2016). https://doi.org/10.1007/s11920-016-0708-z

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