Deliberate self-harm and suicidal ideation among male Iraq/Afghanistan-era veterans seeking treatment for PTSD

Health conditions seen frequently in hospitalized United States Veterans who served after 9/11/2001: A scoping review

BACKGROUND

Hospitalists working outside the Veterans Affairs (VA) system frequently will serve Veterans receiving care for acute conditions and/or awaiting transfer to VA facilities.

OBJECTIVE

To perform a scoping review of health conditions and associated outcomes relevant to hospital medicine in US Veterans who served in active duty or reserve deployed roles after November 9, 2001.

METHODS

A search of MEDLINE and Embase was performed using a combination of terms related to military service period and health conditions, yielding 5634 citations published after January 1, 2013.

STUDY SELECTION AND DATA EXTRACTION

Two reviewers performed independent screening at the title/abstract and later at the full-text levels. Conflicts at both stages were resolved through discussion. Single reviewers extracted data and synthesized results into three categories: (1) mental health and nonblast trauma, (2) neurologic outcomes, and (3) other conditions, including cardiovascular and respiratory outcomes.

RESULTS

Of 85 included studies, 19 focused on cardiovascular, respiratory, autoimmune, and multisystem outcomes; 38 focused on mental health and nonblast trauma; and 28 focused on traumatic brain injury and neurologic outcomes. Studies showed high rates of comorbid mental health diagnoses and suicide-related behaviors relative to non-Veteran populations, as well as relatively younger incidence of cardiovascular and respiratory chronic conditions, such as atrial fibrillation.

CONCLUSIONS

Most studied health conditions among Veterans of post-9/11 conflicts have focused on areas of particular importance to the VA. However, significant gaps remain, particularly in understanding the correlation between specific exposures and clinical outcomes currently observed and to be anticipated in the future in this population.

Non-suicidal self-injury in trichotillomania and skin picking disorder

BACKGROUND

Trichotillomania and skin picking disorder have been characterized as body-focused repetitive behavior (BFRB) disorders (i.e., repetitive self-grooming behaviors that involve biting, pulling, picking, or scraping one's own hair, skin, lips, cheeks, or nails). Trichotillomania and skin picking disorder have also historically been classified, by some, as types of compulsive self-injury as they involve repetitive hair pulling and skin picking, respectively. The question of the relationship of these disorders to more conventional forms of self-injury such as cutting or self-burning remains incompletely investigated. The objective of this study was to examine the relationship of these two disorders with non-suicidal self-injury (NSSI).

METHODS

Adults with trichotillomania (n = 93) and skin picking (n = 105) or both (n = 82) were recruited from the general population using advertisements and online support groups and completed an online survey. Participants completed self-report instruments to characterize clinical profiles and associated characteristics. In addition, each participant completed a mental health history questionnaire.

RESULTS

Of the 280 adults with BFRB disorders, 141 (50.1%) reported a history of self-injury independent of hair pulling and skin picking. Participants with a history of self-injury reported significantly worse pulling and picking symptoms (p < .001) and were significantly more likely to have co-occurring alcohol problems (p < .001), borderline personality disorder (p < .001), buying disorder (p < .001), gambling disorder (p < .001), compulsive sex behavior (p < 001), and binge eating disorder (p = .041).

CONCLUSIONS

NSSI appears common in trichotillomania and skin picking disorder and may be part of a larger constellation of behaviors associated with impulse control or reward-related dysfunction.

Risk and protective factors for self-harm and suicide behaviours among serving and ex-serving personnel of the UK Armed Forces, Canadian Armed Forces, Australian Defence Force and New Zealand Defence Force: A systematic review

BACKGROUND

Self-harm and suicide behaviours are a major public health concern. Several factors are associated with these behaviours among military communities. Identifying these factors may have important implications for policy and clinical services. The aim of this review was to identify the risk and protective factors associated with self-harm and suicide behaviours among serving and ex-serving personnel of the United Kingdom Armed Forces, Canadian Armed Forces, Australian Defence Force and New Zealand Defence Force.

METHODS

A systematic search of seven online databases (PubMed, Web of Science, Embase, Global Health, PsycINFO, PTSDpubs and CINAHL) was conducted alongside cross-referencing, in October 2022. Following an a priori PROSPERO approved protocol (CRD42022348867), papers were independently screened and assessed for quality. Data were synthesised using a narrative approach.

RESULTS

Overall, 28 papers were included: 13 from Canada, 10 from the United Kingdom, five from Australia and none from New Zealand. Identified risk factors included being single/ex-relationship, early service leavers, shorter length of service (but not necessarily early service leavers), junior ranks, exposure to deployment-related traumatic events, physical and mental health diagnoses, and experience of childhood adversity. Protective factors included being married/in a relationship, higher educational attainment, employment, senior ranks, and higher levels of perceived social support.

CONCLUSION

Adequate care and support are a necessity for the military community. Prevention and intervention strategies for self-harm and suicide behaviours may be introduced early and may promote social networks as a key source of support. This review found a paucity of peer-reviewed research within some populations. More peer-reviewed research is needed, particularly among these populations where current work is limited, and regarding modifiable risk and protective factors.

Nonsuicidal self-injury characteristics: A mixed methods analysis of differences between veterans and civilians

Nonsuicidal self-injury (NSSI) is a well-established risk factor for suicidal behavior, with certain NSSI characteristics being associated with increased risk. In the United States (U.S.), the veteran suicide rate is elevated, though lifetime prevalence rates of NSSI appear similar between veterans and civilians. There is limited research that directly compares veterans and civilians across multiple NSSI characteristics to examine between-group differences in NSSI behavior and provide important context for the application of NSSI research with the veteran population. This study examined differences between U.S. veterans and civilians with a history of suicidal ideation across several NSSI characteristics, including method, severity, age of onset, shame, distress, and reason for initial NSSI engagement. A sample of 527 veterans and civilians completed measures of direct and indirect NSSI behaviors along with supplemental questions designed to further assess endorsed NSSI behaviors. Additionally, respondents provided written responses to an open-ended question about their reasons for initial engagement in NSSI, which were coded for post-hoc analysis. Chi-square difference tests and t-tests were conducted, revealing significant group differences between veterans and civilians in NSSI method, lifetime versatility, age of onset, age at last occurrence, and reasons for initial engagement. No significant differences were found in NSSI frequency, severity, shame, or distress. These findings provide valuable information on similarities and differences in NSSI behavior characteristics between U.S. veterans and civilians with lifetime suicidal ideation to inform future research and the assessment of NSSI in these populations.

The Prevalence of Nonsuicidal Self-Injury in Military Personnel: A Systematic Review and Meta-Analysis

Military service members and veterans (SMVs) are at risk for self-directed violence, including nonsuicidal self-injury (NSSI). While NSSI is an important construct worthy of independent study, it is understudied among SMVs and, when included in research, typically examined in the context of suicide risk. Consequently, lifetime prevalence rate estimates of NSSI among SMVs vary. This Preferred Reporting Items for Systematic Reviews and Meta-Analyses systematic review and meta-analysis estimated the average lifetime NSSI prevalence among SMVs and explored demographic and methodological factors that may account for observed variability. Based on a search of Ovid MEDLINE, Embase, PsycINFO, and Web of Science, 47 samples from 42 articles across five countries met inclusion criteria. Results revealed an average NSSI lifetime prevalence rate of 15.76% among SMVs. Significantly higher prevalence rates were observed among clinical (28.14%) versus community (11.28%) samples and studies using interviews to assess NSSI (23.56%) versus self-report (13.44%) or chart review (7.84%). Lifetime prevalence increased as publication year increased and decreased as sample size increased. In contrast to prior literature, prevalence rates were comparable between active-duty SMVs, and studies collecting data anonymously versus those that did not. Lifetime prevalence was not moderated by age, gender, race, country, primary research focus, quality of NSSI operationalization, or whether NSSI methods were assessed. Findings suggest NSSI is a pervasive problem among military personnel, particularly within clinical settings, highlighting the need for systematic assessment of this important but understudied clinical phenomenon among SMVs. Further research is necessary to elucidate additional risk factors for NSSI among SMVs, including trauma exposure.

Prevalence and Correlates of Hair Pulling Disorder and Skin Picking Disorder in an Acute Psychiatric Sample

Hair pulling disorder (HPD; trichotillomania) and skin picking disorder (SPD; excoriation disorder) are understudied psychiatric disorders. The aim of this study was to examine the prevalence and correlates of HPD and SPD in an acute psychiatric sample. Semistructured interviews and self-report measures were administered to patients in a psychiatric partial hospital (N = 599). The past-month prevalence of HPD and SPD was 2.3% and 9%, respectively. HPD and SPD had highly similar clinical characteristics and a strong co-occurrence. Patients with HPD/SPD were significantly younger than other patients and more likely to be female. Logistic regression controlling for age and sex showed that diagnosis of HPD/SPD was not significantly associated with suicidal ideation, suicidal behaviors, nonsuicidal self-injury, or emotional disorder diagnoses (e.g., borderline personality disorder, major depressive disorder). HPD/SPD status was significantly associated with an increased risk of generalized anxiety disorder. However, patients with HPD/SPD did not differ from other patients on self-report measures of generalized anxiety, depression, and distress intolerance. HPD and SPD are common and frequently co-occurring disorders in psychiatric settings.

Characteristics associated with non-suicidal self-injury among veterans seeking military sexual trauma-related mental healthcare

Military sexual trauma (MST) is a serious issue among Veterans; it is associated with increased rates of posttraumatic stress disorder (PTSD) and nonsuicidal self-injury (NSSI), both of which are correlated with poorer mental health outcomes, including increased suicide risk. Additional insight into the characteristics associated with NSSI among Veterans with MST can help identify individuals at increased risk for suicide and other negative outcomes and improve care for Veterans with a history of MST. The current study was comprised of 327 Veterans referred for MST-related mental health services at a VHA hospital. Participants completed a semi-structured interview for clinical symptoms, including NSSI behaviors. Results of a retrospective chart review revealed a high endorsement of lifetime NSSI (26.9%) with cutting behaviors identified as the most frequently endorsed method. Logistic regression showed personality features, history of cumulative sexual trauma, and younger age were uniquely related to lifetime NSSI. These results corroborate previous findings that show elevated rates of NSSI among Veterans with exposure to trauma. This study expands upon previous findings by examining risk factors specific to treatment-seeking Veterans with a history of MST, which can aid clinical care and risk management procedures in Veteran healthcare.

Traditional Masculine Gender Role Norms and Nonsuicidal Self-Injury in Veterans

Reducing Veteran rates of suicide has long remained a top priority for the Veterans Health Administration, and as such, identifying correlates of suicidal behaviors is important to develop targeted interventions. Nonsuicidal self-injury (NSSI) has been identified as a robust predictor of suicide attempts; however, less is known about correlates of NSSI that may aid in upstream prevention efforts. Prior research suggests adherence to various traditional masculine gender role norms may be positively associated with NSSI. Thus, as the U.S. military is widely recognized for promoting and rewarding such norms, this study sought to build off previous research by examining the association between adherence to various masculine gender role norms and engagement in NSSI behaviors among a mixed-sex sample of U.S. Veterans (N = 124). Results showed the norm of emotional control was most strongly associated with lifetime engagement in NSSI behaviors (including the behavior of wall-object punching), whereas the norm of violence was associated with NSSI disorder. Interestingly, exploratory analyses indicated that these associations were primarily driven by women Veterans and sexual orientation status. Overall, the results highlight the importance of assessing for adherence to masculine gender role norms among all Veterans and speak to additional avenues for future research.

Attention-deficit/hyperactivity disorder and nonsuicidal self-injury among veterans with complex psychiatric presentations

Prior research suggests a possible association between attention-deficit/hyperactivity disorder (ADHD) symptoms and nonsuicidal self-injury (NSSI) in veterans. However, this association has not yet been replicated. The present study sought to replicate and expand upon this association in a gender-balanced sample of veterans (N = 124), more than half of whom had a lifetime history of NSSI. Contrary to hypotheses, adult ADHD symptoms were not associated with NSSI history or disorder. Instead, our findings suggest that disorders characterized by negative affect may have greater utility for predicting NSSI versus those characterized by impulsivity. Further research in epidemiological samples is needed.

Men who self-harm-A scoping review of a complex phenomenon

BACKGROUND

To understand and care for men who self-harm, it is important that healthcare professionals have understanding of how and why men self-harm, men's experiences of self-harm and what can be done to hinder or prevent self-harm.

AIMS

The aim of this study was to synthesize the existing knowledge on men who self-harm, with a special emphasis on background, self-harming methods, experiences and reported therapeutic interventions and/or care approaches.

DESIGN

Scoping review of internationally published and grey literature, based on a methodological framework by Arksey and O'Malley.

DATA SOURCES

Systematic electronic database searches were conducted in CINAHL, MEDLINE (Ovid) and PsycINFO. From a total of 684 studies found, 24 studies met the inclusion criteria: full-text, published in English, peer-reviewed studies and grey literature including a focus on men who self-harm, men aged between 18 and 65 years, and published between 2010 and 2019.

RESULTS

Men's self-harm was understood as being related to mental disorders, a means of affect regulation, a loss of self-control, and a means of interpersonal communication. Self-harm can be a positive or negative experience, and there is a wide variety in the methods that men use to self-harm: sharp objects, injection, ingestion, without aids or riskful behaviour. Few studies reported on therapeutic interventions and/or care approaches for men who self-harm.

CONCLUSION

Men's self-harm should be understood as a complex, socially and culturally conditioned phenomenon and studied from a multitude of perspectives.

IMPACT

This scoping review concludes that self-harm among men should be understood as a complex, socially and culturally conditioned phenomenon. To empower men and support their recovery from self-harm, a person-centred approach should be incorporated into research on the subject and practice.

Implicit Associations of Nonsuicidal Self-Injury with Relief in Posttraumatic Stress and Depressive Disorders

OBJECTIVE

Although once considered a defining feature of borderline personality disorder, research has found high rates of NSSI among individuals with other psychiatric disorders, particularly posttraumatic stress disorder (PTSD) and depressive disorders. A recent study from our research team found that lifetime PTSD and depressive disorders were associated with unique self-reported NSSI motives. Given well-established limitations of assessing motives via self-report measures, the present study sought to extend this line of research by using a novel laboratory measure of the implicit NSSI-relief association to examine NSSI emotional relief motives.

METHOD

A subset of participants from our previous study (N = 109) completed diagnostic interviews and the laboratory-based DSH-Relief Implicit Association Test (IAT).

RESULTS

Findings indicated that individuals with lifetime PTSD evidenced stronger NSSI-relief associations than those without PTSD. Further, this main effect was qualified by a PTSD by depressive disorder interaction, such that stronger NSSI-relief associations were found among individuals with lifetime PTSD but no lifetime depressive disorder than among individuals without a history of either PTSD or a depressive disorder.

CONCLUSIONS

Results highlight the importance of investigating NSSI motives associated with different symptom profiles using a multi-method approach.

Fluid vulnerability theory as a framework for understanding the association between posttraumatic stress disorder and suicide: A narrative review

Suicide is a persistent issue in the United States and across the globe. A large body of published research shows that posttraumatic stress disorder (PTSD) increases the risk of suicidal ideation, suicidal behaviors, and death by suicide. However, the existing literature examining why that association might pertain is widely dispersed across disciplines (e.g., psychology, nursing) and lacks an integrative theoretical framework, making it difficult to conceptualize the current state of science in this area. Therefore, the primary aims of this narrative review were to (a) provide a comprehensive and interdisciplinary critique of the current state of knowledge regarding mechanisms that underlie the association between PTSD and suicide and (b) organize that knowledge according to a specified theoretical framework. The framework guiding this review is "fluid vulnerability theory," a diathesis-stress model of suicide that emphasizes the dynamic nature of suicide risk across cognitive, emotional, behavioral, and physiological domains. A summary of the findings, including patterns that emerged, gaps that remain, and recommendations for the advancement of science and practice in this area are addressed in this narrative review.

Non-suicidal self-injury in US military veterans: Results from the National Health and Resilience in Veterans Study

BACKGROUND

To evaluate the prevalence of lifetime non-suicidal self-injury (NSSI) among US military veterans and identify sociodemographic, military, psychiatric and clinical correlates associated with NSSI.

METHODS

Data were analysed from the 2019-2020 National Health and Resilience in Veterans Study, a contemporary, nationally representative survey of 4069 US veterans. Outcomes measured included lifetime history of NSSI, trauma history, lifetime and current DSM-V mental disorders and lifetime and recent suicidal behaviours.

RESULTS

The overall prevalence of lifetime NSSI was 4.2% (95% confidence interval [3.6%, 4.9%]). Multivariable analyses revealed that veterans who endorsed lifetime NSSI were more likely to be younger, female, non-Caucasian, unmarried or unpartnered, and to have a lower annual household income. Veterans who endorsed lifetime NSSI reported more adverse childhood experiences and lifetime traumas and were more likely to have experienced military sexual trauma. They also were more likely to screen positive for lifetime posttraumatic stress disorder, major depressive disorder (MDD) and substance use disorders and to have attempted suicide. Finally, lifetime NSSI was associated with current MDD, generalized anxiety disorder, and substance use disorders, as well as past-year suicidal ideation.

CONCLUSION

Results of this study provide the first-known data on the epidemiology of NSSI in US military veterans. They suggest that certain correlates can help identify veterans who may be at greater risk for engaging in NSSI, as well as the potential prognostic utility of lifetime NSSI in predicting current psychiatric problems and suicide risk in this population.

Nonsuicidal Self-Injury Disorder, Borderline Personality Disorder, and Lifetime History of Suicide Attempts among Male and Female Veterans with Mental Health Disorders

BACKGROUND

Expanding on research that has identified nonsuicidal self-injury (NSSI) as a strong predictor of suicide risk, the present study examined NSSI disorder (NSSID) and borderline personality disorder (BPD) as unique contributors to lifetime suicide attempts. To our knowledge, the present study represents the first exploration of these associations among veterans.

METHODS

Participants included 124 male (74%) and female (26%) veterans diagnosed with at least one mental health disorder. Posttraumatic stress disorder (93%) and major depression (86%) were the most common mental health diagnoses. Large proportions of the sample met criteria for NSSID (48%) and BPD (40%). Suicide attempts were reported by 28% of the sample. Chi-square tests determined the bivariate associations among NSSID, BPD, history of suicide attempts, and other variables. Significant diagnostic (i.e., MDD, BPD, and NSSID) and demographic (i.e., age) characteristics were included as covariates in a logistic regression model examining the associations of BPD and NSSID with suicide attempts.

RESULTS

BPD, Χ²=11.1, p<0.001, and NSSID, Χ²=13.9, p<0.001, were uniquely associated with suicide attempts. When all significant predictors were included in the final model, only NSSID emerged as a significant contributor to suicide attempts, OR = 4.9, p < 0.001.

LIMITATIONS

Causality cannot be determined from cross-sectional analyses.

CONCLUSION

These findings highlight NSSID as a powerful and unique correlate of suicide attempts among veterans, beyond the associations of established diagnostic risk factors. Improving our understanding of the relationship between NSSID and suicide risk has the potential to inform suicide prevention efforts and improve clinical outcomes among veterans.

Diagnostic Correlates of Nonsuicidal Self-Injury Disorder among Veterans with Psychiatric Disorders

With its recent inclusion in the Diagnostic and Statistical Manual, nonsuicidal self-injury disorder (NSSID) has received limited research attention, especially in samples of military veterans. The present study sought to identify diagnostic predictors of NSSID within a veteran sample. Study participants included 124 veterans with at least one psychiatric diagnosis. Chi-square tests and t-tests evaluated bivariate associations between NSSID and twenty diagnostic correlates. Logistic regression models identified psychiatric disorders that were unique correlates of NSSID among veterans. Veterans with lifetime NSSID (n = 59) met criteria for a greater number of lifetime disorders than veterans with other psychiatric disorders. Bivariate associations were noted between NSSID and borderline personality disorder, depression, obsessive-compulsive disorder, generalized anxiety disorder, and cannabis use disorder. In the logistic regression model, only borderline personality disorder (AOR = 7.67) and obsessive-compulsive disorder (AOR = 3.23) continued to be associated with NSSID. The present study represents the first examination of the association between NSSID and psychiatric disorders among veterans. The findings shed light on psychiatric disorders associated with lifetime NSSID in veterans, with special consideration toward obsessive-compulsive disorder as a risk factor for NSSID.

Psychological inflexibility processes and nonsuicidal self-injury: Concurrent and prospective associations

OBJECTIVE

The aim of this study was to examine concurrent and 3-month prospective associations between a multidimensional measure of psychological inflexibility and nonsuicidal self-injury (NSSI) among participants with a self-harm history.

METHOD

Participants completed measures of NSSI, psychological inflexibility, negative urgency, and depression at baseline (N = 106, M_age  = 34.70, SD = 9.43, 66% women), and were again assessed at follow-up (N = 86).

RESULTS

Participants currently engaging in NSSI reported significantly higher psychological inflexibility as compared to those who have ceased NSSI. After controlling for covariates, psychological inflexibility was concurrently associated with NSSI recency and longitudinally predicted perceived likelihood of future NSSI. Psychological inflexibility was not associated with new NSSI acts after including baseline covariates. Finally, psychological inflexibility subscales demonstrated differential relationships with various NSSI functions.

CONCLUSION

Results highlight the psychological inflexibility model's utility in understanding NSSI and have implications for future research that may inform clinical practice.

Characteristics of nonsuicidal self-injury among veterans

OBJECTIVE

The current study aimed to (a) assess basic nonsuicidal self-injury (NSSI) characteristics using a validated clinical interview among a sample of veterans not recruited for specific diagnostic or environmental criteria and (b) examine the relation between NSSI and medical severity of prior suicide attempts (SAs) among veterans.

DESIGN

We conducted secondary data analyses among a combined sample of veterans (N = 165) from two parent studies conducted at a large VA Medical Center that implemented identical recruitment protocols. No psychiatric criteria were utilized for inclusion or exclusion purposes.

RESULTS

Approximately 16% of participants reported NSSI history and almost 21% reported SA history. NSSI history was associated with probability of prior SA but not the medical severity of prior SA.

CONCLUSIONS

NSSI is a prevalent concern among veterans and is associated with probability of SA. It remains unclear whether prior NSSI is associated with more medically serious SA in this population.

Body-focused repetitive behaviors and non-suicidal self-injury: A comparison of clinical characteristics and symptom features

Body-focused repetitive behaviors (BFRBs) and non-suicidal self-injury (NSSI) are recognized as distinct categories in the DSM-5. However, definitions and assessment of NSSI sometimes encompasses behaviors similar to BFRBs, and little data exist about their clinical differences. The current study examined clinical characteristics and symptom features associated with NSSI vs. BFRBs. The current sample included 1523 individuals who endorsed moderate to severe NSSI (n = 165) or BFRBs: hair pulling group (n = 102), skin picking group (n = 216), nail picking group (n = 253), nail biting group (n = 487), and cheek biting group (n = 300). Responders were asked to complete questionnaires on clinical features relevant for BFRBs and NSSI. NSSI and BFRBs had significant differences on several clinical features. Individuals in the NSSI group were more likely than individuals with BFRBs to report engaging in the behavior for social-affective reasons (i.e., to get out of doing something, or receive attention from others). Individuals in the NSSI group were also more likely to engage in the behavior to regulate tension and feelings of emptiness, and to experience relief during the act. In contrast, individuals in the BFRB groups were more likely to engage in the behavior automatically without reflective awareness, to reduce boredom, or to fix appearance. The NSSI group obtained significantly higher scores on questionnaires assessing stress, anxiety, depression, and harm avoidance. Overall, the results showed several notable differences between NSSI and BFRBs that are consistent with clinical literature and definitions of these problems in the DSM-5.

Self- and Other-Directed Violence as Outcomes of Deployment-Based Military Sexual Assault in Iraq/Afghanistan-era Veteran Men and Women

Although military sexual assault (MSA) has been well-established as a risk factor for psychopathology (e.g., PTSD, depression), little research has examined the association between MSA and self- and other-directed violence. Furthermore, there has been a growing empirical focus on potential gender differences in the effects of MSA, but few of these studies have examined gender differences in self- and other-directed violence. In a sample of 1571 Iraq/Afghanistan-era veterans (21.0% women), we examined the effect of MSA on difficulty controlling violent behavior and attempting suicide among veteran men and women, above and beyond the influence of childhood sexual abuse, combat trauma, PTSD, and major depressive disorder. Results of a logistic regression revealed that MSA increased risk of attempting suicide and difficulty controlling violence among women but not men. Thus, the results suggest that MSA may be a risk factor for both types of violence in women. Furthermore, because PTSD was associated with both types of violence in both men and women, MSA may also confer risk of violence via PTSD.

Non-suicidal self-injury, suicide ideation, and past suicide attempts: Comparison between transgender and gender diverse veterans and non-veterans

BACKGROUND

Transgender and gender diverse (TGD) individuals, especially veterans, experience elevated rates of non-suicidal self-injury (NSSI) and suicide related behaviors compared to gender majority individuals. Research has yet to compare TGD veterans to non-veterans or look at correlates of NSSI and related behaviors to suicide related outcomes. This study examines prevalence and suicide related correlates of NSSI among TGD veterans and TGD non-veterans.

METHOD

Data analyzed in the were part of the Trans Lifeline Mental Health Survey. Both TGD veterans (N = 313) and non-veterans (N = 3,972) completed an online, cross-sectional survey that included self-report measures of NSSI, suicidal ideation (SI), and suicidal attempt (SA) along with lifetime hospitalization and avoidance of care due to NSSI.

RESULTS

Results of this paper indicate that prevalence of NSSI, SI, and SA are elevated in both the TGD veterans and non-veteran subpopulations. Further, veterans compared to non-veterans have a lower prevalence of NSSI but higher prevalence of hospitalization when self-harm is inflicted, reflecting more healthcare utilization or increased severity of NSSI episodes. Additionally, veterans were less likely to avoid care due to NSSI. Further, veteran status seemed to be a protective factor against demographic differences that increased rates of NSSI history in non-veteran TGD individuals.

LIMITATIONS

The limitations of this study include its cross-sectional study design, one question assessing SA, and few TGD male veterans.

CONCLUSION

NSSI is an important risk factor in future suicide related outcome such as SI and SA. Further, differences in healthcare utilization among TGD veterans and non-veterans are apparent.

Non-suicidal self-injury prevalence, course, and association with suicidal thoughts and behaviors in two large, representative samples of US Army soldiers

BACKGROUND

Non-suicidal self-injury (NSSI) prospectively predicts suicidal thoughts and behaviors in civilian populations. Despite high rates of suicide among US military members, little is known about the prevalence and course of NSSI, or how NSSI relates to suicidal thoughts and behaviors, in military personnel.

METHODS

We conducted secondary analyses of two representative surveys of active-duty soldiers (N = 21 449) and newly enlisted soldiers (N = 38 507) from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS).

RESULTS

The lifetime prevalence of NSSI is 6.3% (1.2% 12-month prevalence) in active-duty soldiers and 7.9% (1.3% 12-month prevalence) in new soldiers. Demographic risk factors for lifetime NSSI include female sex, younger age, non-Hispanic white ethnicity, never having married, and lower educational attainment. The association of NSSI with temporally primary internalizing and externalizing disorders varies by service history (new v. active-duty soldiers) and gender (men v. women). In both active-duty and new soldiers, NSSI is associated with increased odds of subsequent onset of suicidal ideation [adjusted odds ratio (OR) = 1.66-1.81] and suicide attempts (adjusted OR = 2.02-2.43), although not with the transition from ideation to attempt (adjusted OR = 0.92-1.36). Soldiers with a history of NSSI are more likely to have made multiple suicide attempts, compared with soldiers without NSSI.

CONCLUSIONS

NSSI is prevalent among US Army soldiers and is associated with significantly increased odds of later suicidal thoughts and behaviors, even after NSSI has resolved. Suicide risk assessments in military populations should screen for history of NSSI.

Nonsuicidal Self-Injury and Borderline Personality Features as Risk Factors for Suicidal Ideation Among Male Veterans With Posttraumatic Stress Disorder

U.S. veterans are at increased risk for suicide compared to their civilian counterparts and account for approximately 20% of all deaths by suicide. Posttraumatic stress disorder (PTSD) and borderline personality features (BPF) have each been associated with increased suicide risk. Additionally, emerging research suggests that nonsuicidal self-injury (NSSI) may be a unique risk factor for suicidal behavior. Archival data from 728 male veterans with a PTSD diagnosis who were receiving care through an outpatient Veterans Health Administration (VHA) specialty PTSD clinic were analyzed. Diagnosis of PTSD was based on a structured clinical interview administered by trained clinicians. A subscale of the Personality Assessment Inventory was used to assess BPF, and NSSI and suicidal ideation (SI) were assessed by self-report. Findings revealed that NSSI (58.8%) and BPF (23.5%) were both relatively common in this sample of male veterans with PTSD. As expected, each condition was associated with significantly increased odds of experiencing SI compared to PTSD alone, odds ratios (ORs) = 1.2-2.6. Moreover, co-occurring PTSD, NSSI, and BPF were associated with significantly increased odds of experiencing SI compared with PTSD, OR = 5.68; comorbid PTSD and NSSI, OR = 2.57; and comorbid PTSD and BPF, OR = 2.13. The present findings provide new insight into the rates of NSSI and BPF among male veterans with PTSD and highlight the potential importance of these factors in suicide risk.

Extreme challenges: psychiatric inpatients with severe self-harming behavior in Norway: a national screening investigation

BACKGROUND

Extreme self-harming behavior is a major challenge for patients and health services. Nevertheless, this patient population is poorly described in research literature.

AIMS

The aim of this study was to assess the volume of patients with extensive psychiatric hospitalization due to extreme self-harming behaviors, the extent of severe medical sequelae, and collaboration problems within health services.

METHODS

In a national screening investigation, department managers in 83 adult psychiatric inpatient institutions across all health regions in Norway were invited to participate in a brief, prepared, telephone interview.

RESULTS

Sixty-one interviews were completed. Extensive hospitalization (prolonged or multiple) due to extreme self-harm was reported for the last year in all health regions and in 427 individual cases. Mean number of cases did not differ by region. Psychiatric hospitalizations were more frequent in hospital units than mental health centers. In 109 of the cases, self-harming behavior had severe medical consequences, including five deaths. In 122 of the cases, substantial collaboration problems within the health services were reported (disagreements on diagnosis, treatment needs and resources). Extensive (long-term) hospitalization was particularly associated with the combination of severe medical sequelae and collaboration problems.

CONCLUSION

This investigation confirms a noteworthy, nationwide, population of severely self-harming inpatients with extensive health service use, prevalent severe medical complications, and unsatisfactory collaboration within health services. These preliminary results are alarming, and indicate a need for more profound understanding of highly complex and severe cases.

Wall/Object Punching: An Important but Under-Recognized Form of Nonsuicidal Self-Injury

The present research investigated wall/object punching as a form of nonsuicidal self-injury (NSSI) among 1,143 veterans seeking treatment for posttraumatic stress disorder (PTSD). Wall/object punching was remarkably common in this sample (43%), and its inclusion in the definition of NSSI increased estimated prevalence of recent NSSI by 14%. As expected, wall/object punching was strongly associated with other traditional forms of NSSI, post-NSSI relief, and suicide ideation. Male veterans and veterans with PTSD were significantly more likely to engage in wall/object punching than female veterans and veterans without PTSD. More research on this important but under-recognized form of NSSI is needed.

Examination of the indirect effects of combat exposure on suicidal behavior in veterans

BACKGROUND

Researchers have theorized that increased rates of suicide in the military are associated with combat exposure; however, this hypothesis has received inconsistent support in the literature, potentially because combat exposure may be indirectly related to suicide risk through its influence on posttraumatic stress disorder (PTSD) and depressive symptoms. The current study tested the hypothesis that combat exposure has a significant indirect effect on suicidal behavior among Iraq/Afghanistan-era veterans through its effects on PTSD-depressive symptomatology.

METHODS

Iraq/Afghanistan-era veterans (N = 3,238) participated in a cross-sectional, multi-site study of post-deployment mental health consisting of clinical interviews and self-report questionnaires. Structural equation modeling (SEM) was used to examine direct and indirect relationships between three latent variables: combat exposure, PTSD-depression, and suicidal behavior (past attempts and current ideation, intent, and preparation).

RESULTS

A partial mediation model was the best-fitting model for the data. Combat exposure was significantly associated with PTSD-depression (β = 0.50, p < .001), which was in turn associated with suicidal behavior (β = 0.62, p < .001). As expected, the indirect effect between combat exposure and suicidal behavior was statistically significant, β = 0.31, p < .001.

LIMITATIONS

Data were cross-sectional, and suicidal behavior was measured via self-report.

CONCLUSIONS

Results indicated that combat exposure was indirectly related to suicidal behavior via PTSD-depressive symptomatology. Findings lend support for a higher-order combined PTSD-depression latent factor and suggest that Iraq/Afghanistan-era veterans with high levels of PTSD-depressive symptoms are at increased risk for suicidal behavior.

The Impact of Cannabis Use Disorder on Suicidal and Nonsuicidal Self-Injury in Iraq/Afghanistan-Era Veterans with and without Mental Health Disorders

The objective of this study was to assess the association between cannabis use disorder (CUD) and self-injury among veterans. As expected, after adjusting for sex, age, sexual orientation, combat exposure, traumatic life events, traumatic brain injury, posttraumatic stress disorder, depression, alcohol use disorder, and noncannabis drug use disorder, CUD was significantly associated with both suicidal (OR = 3.10, p = .045) and nonsuicidal (OR = 5.12, p = .009) self-injury. CUD was the only variable significantly associated with self-injury in all three models examined. These findings are consistent with prior research among civilians and suggest that CUD may also increase veterans' risk for self-injurious behavior.

ADHD and nonsuicidal self-injury in male veterans with and without PTSD

The objective of the present research was to examine the association between ADHD symptoms and nonsuicidal self-injury (NSSI) in male Iraq/Afghanistan-era veterans with and without PTSD. Approximately 25% of veterans screened positive for clinically-significant levels of ADHD. Male veterans with PTSD were significantly more likely to report ADHD symptoms than male veterans without PTSD. In addition, as expected, ADHD was strongly associated with NSSI, even after accounting for the effects of demographic variables, PTSD, depression, and alcohol use disorder. Future work aimed at replicating and extending these findings in longitudinal studies of veterans is needed.

Nonsuicidal self-injury and interpersonal violence in U.S. veterans seeking help for posttraumatic stress disorder

Nonsuicidal self-injury (NSSI) has been defined as deliberately damaging one's body tissue without conscious suicidal intent. NSSI is a robust predictor of suicidal ideation and attempts in adults. While NSSI has been associated with other-directed violence in adolescent populations, the link between NSSI and interpersonal violence in adults is less clear. The current study examined the cross-sectional relationship between NSSI and past-year interpersonal violence among 729 help-seeking veterans with posttraumatic stress disorder (PTSD). Veterans who reported a recent history of engaging in cutting, hitting, or burning themselves were significantly more likely to report making violent threats and engaging in violent acts, including the use of a knife or gun, in the past year than veterans without NSSI. NSSI was uniquely associated with interpersonal violence after controlling for a variety of dispositional, historical, contextual, and clinical risk factors for violence, including age, race, socio-economic status, marital status, employment status, combat exposure, alcohol misuse, depression, PTSD symptom severity, and reported difficulty controlling violence. These findings suggest that clinicians working with veterans with PTSD should review NSSI history when conducting a risk assessment of violence.

Nonsuicidal self-injury and suicide attempts in Iraq/Afghanistan war veterans

The present study examined the association between history of nonsuicidal self-injury (NSSI) and history of suicide attempts (SA) among 292 Iraq/Afghanistan veterans, half of whom carried a lifetime diagnosis of posttraumatic stress disorder (PTSD). Consistent with hypotheses, veterans who reported a history of NSSI were significantly more likely to report a history of SA than veterans without a history of NSSI. In addition, logistic regression demonstrated that NSSI remained a significant predictor of SA even after a wide range of covariates (i.e., combat exposure, traumatic brain injury, PTSD, depression, alcohol dependence) were considered. Taken together, these findings suggest that clinicians working with veterans should include NSSI history as part of their standard risk assessment battery.

Attentional processes in posttraumatic stress disorder and the associated changes in neural functioning

Posttraumatic Stress Disorder (PTSD) is associated with alterations in attention at the behavioral and neural levels. However, there are conflicting findings regarding the specific type of attention impairments present in PTSD, as the commonly used tests of attention do not isolate the mechanisms behind attention abnormalities, and the constructs measured do not map onto the neurocircuits governing attention. Here, we review the literature on attention processing in PTSD and offer directions for future research to clarify these unanswered questions. First, using instruments that allow assessment of behavioral and neurophysiological attention components will be necessary to understand attention deficits in PTSD. Second, focus on intra-individual variability in addition to assessment of central tendency may help clarify some of the mixed findings. Third, longitudinal studies on attentional processes are warranted to determine how attention contributes to the development and maintenance of PTSD. Integration of behavioral and neural measures of attention will be useful in understanding the pathophysiology of PTSD.

Non-suicidal self-injury as a predictor of active and passive suicidal ideation among Iraq/Afghanistan war veterans

The present study examined the association between lifetime non-suicidal self-injury (NSSI) and current suicidal ideation among Iraq/Afghanistan veterans. NSSI was positively associated with passive, active, and concurrent active-passive suicidal ideation at the bivariate level. NSSI remained a predictor of active, OR=5.15, and concurrent active-passive suicidal ideation, OR=7.01, when other risk factors were considered. These findings suggest that NSSI may be a particularly useful marker of active suicidal ideation among veterans.

Prevalence of, risk factors for, and consequences of posttraumatic stress disorder and other mental health problems in military populations deployed to Iraq and Afghanistan

This review summarizes the epidemiology of posttraumatic stress disorder (PTSD) and related mental health problems among persons who served in the armed forces during the Iraq and Afghanistan conflicts, as reflected in the literature published between 2009 and 2014. One-hundred and sixteen research studies are reviewed, most of which are among non-treatment-seeking US service members or treatment-seeking US veterans. Evidence is provided for demographic, military, and deployment-related risk factors for PTSD, though most derive from cross-sectional studies and few control for combat exposure, which is a primary risk factor for mental health problems in this cohort. Evidence is also provided linking PTSD with outcomes in the following domains: physical health, suicide, housing and homelessness, employment and economic well-being, social well-being, and aggression, violence, and criminality. Also included is evidence about the prevalence of mental health service use in this cohort. In many instances, the current suite of studies replicates findings observed in civilian samples, but new findings emerge of relevance to both military and civilian populations, such as the link between PTSD and suicide. Future research should make effort to control for combat exposure and use longitudinal study designs; promising areas for investigation are in non-treatment-seeking samples of US veterans and the role of social support in preventing or mitigating mental health problems in this group.