Self-harm and suicidal behavior in women with comorbid PTSD and substance dependence

Identifying factors associated with opioid cessation in a biracial sample using machine learning

Aim

Racial disparities in opioid use disorder (OUD) management exist, however, and there is limited research on factors that influence opioid cessation in different population groups.

Methods

We employed multiple machine learning prediction algorithms least absolute shrinkage and selection operator, random forest, deep neural network, and support vector machine to assess factors associated with ceasing opioid use in a sample of 1,192 African Americans (AAs) and 2,557 individuals of European ancestry (EAs) who met Diagnostic and Statistical Manual of Mental Disorders, 5th Edition criteria for OUD. Values for nearly 4,000 variables reflecting demographics, alcohol and other drug use, general health, non-drug use behaviors, and diagnoses for other psychiatric disorders, were obtained for each participant from the Semi-Structured Assessment for Drug Dependence and Alcoholism, a detailed semi-structured interview.

Results

Support vector machine models performed marginally better on average than other machine learning methods with maximum prediction accuracies of 75.4% in AAs and 79.4% in EAs. Subsequent stepwise regression considered the 83 most highly ranked variables across all methods and models and identified less recent cocaine use (AAs: odds ratio (OR) = 1.82, P = 9.19 × 10^-5; EAs: OR = 1.91, P = 3.30 × 10^-15), shorter duration of opioid use (AAs: OR = 0.55, P = 5.78 × 10^-6; EAs: OR = 0.69, P = 3.01 × 10^-7), and older age (AAs: OR = 2.44, P = 1.41 × 10^-12; EAs: OR = 2.00, P = 5.74 × 10^-9) as the strongest independent predictors of opioid cessation in both AAs and EAs. Attending self-help groups for OUD was also an independent predictor (P < 0.05) in both population groups, while less gambling severity (OR = 0.80, P = 3.32 × 10^-2) was specific to AAs and post-traumatic stress disorder recovery (OR = 1.93, P = 7.88 × 10^-5), recent antisocial behaviors (OR = 0.64, P = 2.69 × 10^-3), and atheism (OR = 1.45, P = 1.34 × 10^-2) were specific to EAs. Factors related to drug use comprised about half of the significant independent predictors in both AAs and EAs, with other predictors related to non-drug use behaviors, psychiatric disorders, overall health, and demographics.

Conclusions

These proof-of-concept findings provide avenues for hypothesis-driven analysis, and will lead to further research on strategies to improve OUD management in EAs and AAs.

Anxiety sensitivity and posttraumatic stress symptoms in sexual assault survivors

Anxiety sensitivity (AS), the fear of anxiety-related physiological sensations, is a predictor of posttraumatic stress symptoms (PTSS) following a traumatic event, yet there is limited research on the relationship between AS and PTSS among sexual assault survivors. The present study was designed to test the hypothesis that AS would emerge as a statistical predictor of PTSS dimensions among community members and undergraduate students endorsing lifetime exposure to sexual trauma. Adults endorsing a history of sexual assault (N = 52) completed an online battery, including self-report measures of AS, general distress, dysfunctional trauma-related beliefs (i.e., posttraumatic cognitions), and PTSS. Although AS was associated with PTSS dimensions at the bivariate level (rs ranged .68-82), AS did not emerge as a significant unique predictor of PTSS dimensions in linear regression analyses after controlling for general distress and posttraumatic cognitions. In fact, general distress was the only significant statistical predictor of PTSS total and dimension scores (ps < 01). Study implications, limitations, and future directions are discussed.

The role of depression and suicidal cognitions as contributors to suicide risk among active duty soldiers reporting symptoms of posttraumatic stress disorder

BACKGROUND

Military suicide rates have risen across all service branches, with the overall rate surpassing that of the general population for the first time in history in 2008. Service members with posttraumatic stress disorder (PTSD) are at a substantially higher risk for suicidal ideation, suicide attempts, and death by suicide than their peers without PTSD. While the link between PTSD and suicide is well established in the literature, less is known about the precise nature of that connection. Several constructs have been implicated as potential mediators of this relation, such as depression, alcohol use, suicidal cognitions, and sleep disturbance. Yet, to our knowledge, these constructs have never been examined simultaneously in a single model to determine mediational influence for suicide risk among soldiers with PTSD.

METHODS

A sample of 172 active duty Army soldiers completed a series of measures targeting the aforementioned constructs. Data were analyzed using mediation model analyses.

RESULTS

Suicidal cognitions fully mediated the relation between PTSD symptoms and current suicide risk severity. The indirect effect for suicidal cognitions was significantly larger than indirect effects for alcohol use, depression, and sleep disturbance. Exploratory analyses suggest serial mediation of the relation between PTSD and current suicide risk by depression and suicidal cognitions.

LIMITATIONS

These results should be interpreted within the context of study limitations, to include use of self-report data and inability to firmly establish temporal sequencing assumed in mediation.

CONCLUSIONS

Implications of this study include the improvement of suicide risk assessment and individualized treatment planning for suicidal military personnel with PTSD.

Posttraumatic stress disorder and substance use: Identifying the underlying role of difficulties regulating positive emotions

The co-occurrence of posttraumatic stress disorder (PTSD) and substance use is clinically-relevant. Emotion dysregulation is one factor that has been shown to underlie this association. However, literature in this area has been limited in its exclusive focus on emotion dysregulation stemming from negative emotions. The goal of the current study was to extend prior research by exploring the role of difficulties regulating positive emotions in the associations between PTSD symptom severity and both alcohol use and problems from drug use. Participants were 463 trauma-exposed individuals recruited from Amazon's MTurk (M age = 35.66 years; 55.7% female; 76.6% White). PTSD symptom severity, difficulties regulating positive emotions, alcohol use, and problems from drug use demonstrated significant positive zero-order correlations. Further, difficulties regulating positive emotions were found to account for the associations between PTSD symptom severity and both alcohol use and problems from drug use. Our results suggest the potential utility of addressing difficulties regulating positive emotions in interventions aimed at reducing substance use and abuse among individuals with PTSD.

Recent Suicidal Ideation and Behavior in the General Population: The Role of Depression, Posttraumatic Stress, and Reactive Avoidance

The multivariate relationship between suicidality and three potential etiologic variables (depression, posttraumatic stress, and reactive avoidance) was examined in a stratified sample of 679 individuals from the general population. Lifetime exposure to a trauma or another very upsetting event was prevalent among those reporting suicidal behavior in the previous 6 months (58%) and those reporting recent suicidal ideation alone (40%), relative to those with no recent suicidal thoughts or behaviors (26%). Canonical correlation analysis indicated two independent sources of variance: the first loading on both suicidal ideation and behavior, predicted by depression, posttraumatic stress, and reactive avoidance, and the second indicating a unique relationship between suicidal behavior and reactive avoidance alone. Results indicate that the etiology of suicidality is likely multidimensional, and point to a significant variant of suicidal behavior that is unrelated to depression or posttraumatic stress, but may reflect emotional dysregulation and subsequent distress reduction behaviors.

An investigation of the effect of trauma script exposure on risk-taking among patients with substance use disorders and posttraumatic stress disorder

Studies show that patients with substance use disorders (SUD) and posttraumatic stress disorder (PTSD) are at high risk for engaging in risky behaviors. However, these studies do not speak to the context in which these behaviors are more likely to occur. This study examined whether SUD patients with current PTSD, compared to those without a history of PTSD, are more likely to exhibit risk-taking on a laboratory-based risk-taking task, the Iowa Gambling Task (IGT), following exposure to a personalized trauma script versus a neutral script. The sample consisted of 122 trauma-exposed SUD patients with and without PTSD. Participants were administered a series of diagnostic interviews and personalized trauma scripts were created. On separate days, participants were exposed to a neutral or trauma script, followed by the IGT. Contrary to expectations, PTSD-SUD patients exhibited significantly greater risk-taking after the neutral (vs. trauma) script than those without PTSD. Moreover, whereas SUD patients without PTSD evidenced stability in IGT performance across scripts, those with PTSD exhibited significantly lower risk-taking on the IGT following the trauma (vs. neutral) script. Results provide support for the context dependent nature of risk-taking in PTSD-SUD patients and suggest they may become more risk averse in the context of trauma-related distress.

Grieving Styles of Young Banso Widows

Grieving is manifested differently around the world depending on culture, social desirability, and social norms. Little is known about grieving patterns in Africa. As such, a study of the grieving patterns of young widows of the Banso tribe of the Cameroon was conducted. This examination used Doka and Martin’s model of grieving styles as the lens for this research. This model delineates a continuum of grief styles: instrumental on one end, intuitive on the other, and blended in the middle. This study used the validated Grief Pattern Inventory to determine if young Banso widows in this sample are intuitive, instrumental, or blended grievers. The study employed a cross-sectional design. The results indicated that 47% of the participants were intuitive grievers and 41% were blended grievers. Policy, research, and clinical implications emerging from the results were presented.

Suicidal Ideation and Suicide Attempts among Women Seeking Treatment for Substance Use and Trauma Symptoms

Substance use disorders and posttraumatic stress disorder have been associated with suicide. Through secondary analysis of the screening data from the Women and Trauma Study conducted by the National Institute on Drug Abuse Clinical Trials Network, the present study examined rates and correlates of suicidal ideation and suicide attempts among women who sought treatment for substance use and trauma at seven outpatient substance use programs. The sample included women between the ages of 18 and 65 years (M = 39.2; SD = 9.3) and was 44 percent white, 33 percent African American, 8 percent Latina, and 15 percent other races or ethnicities. Logistic regression was used to examine factors associated with a lifetime history of recurrent suicidal ideation and a serious suicide attempt. Findings highlight the need for social workers to address elevated risk levels for suicidal thoughts and behaviors when working with women with histories of substance use and trauma.

PTSD Symptom Severity and Emotion Regulation Strategy Use During Trauma Cue Exposure Among Patients With Substance Use Disorders: Associations With Negative Affect, Craving, and Cortisol Reactivity

The co-occurrence of posttraumatic stress disorder (PTSD) pathology with a substance use disorder (SUD) is associated with emotion regulation deficits. However, studies in this area generally rely on trait-based emotion regulation measures, and there is limited information on the relation of PTSD pathology to the use of specific emotion regulation strategies in response to trauma-related distress among SUD patients or the consequences of these strategies for trauma cue reactivity. This study examined the relation of PTSD symptom severity to the use of specific emotion regulation strategies during trauma cue exposure among trauma-exposed SUD patients, as well as the indirect relations of PTSD symptom severity to changes in negative affect, cravings, and cortisol levels pre- to posttrauma cue exposure through different emotion regulation strategies. Participants were 133 trauma-exposed SUD patients. Participants listened to a personalized trauma script and reported on emotion regulation strategies used during the script. Data on negative affect, cravings, and cortisol were collected pre- and postscript. PTSD symptom severity related positively to the use of more adaptive (e.g., distraction) and maladaptive (e.g., suppression) regulation strategies. Moreover, evidence for the indirect effects of PTSD symptom severity on negative affect and cortisol reactivity through both adaptive and maladaptive emotion regulation strategies was found. Implications of findings are discussed.

Trauma characteristics, post-traumatic symptoms, psychiatric disorders and suicidal behaviours: Results from the 2007 Australian National Survey of Mental Health and Wellbeing

OBJECTIVE

The current study examined whether trauma characteristics such as the type and number of traumatic events were associated with three suicidal behaviours (i.e. ideation, plan and attempt) after adjusting for sociodemographic factors, post-traumatic symptoms and history of psychiatric disorders.

METHOD

Data came from the 2007 Australian National Survey of Mental Health and Wellbeing ( N = 8841). Respondents were asked about exposure to 28 traumatic events that occurred during their lifetime. Suicidal behaviours were measured using three statements about whether the person ever seriously thought about or planned or attempted suicide.

RESULTS

Sexual violence and exposure to multiple traumatic events were particularly associated with suicidal behaviours. The presence of the emotional numbing symptom cluster and co-occurrence of three psychiatric disorders (major depressive disorder, alcohol use disorder and substance use disorder) also increased the odds of suicidal behaviours. Analysis of age of onset revealed that the mean age of traumatic exposure was earlier than the age at which suicidal behaviours emerged.

CONCLUSIONS

The current study is the first to demonstrate that sexual violence and exposure to multiple traumatic events are associated with suicidal behaviours in a representative sample of Australian adults. The results underline the potential benefits of thorough assessment of trauma history, post-traumatic symptoms and history of psychiatric disorders and their additive contribution in suicide risk among trauma victims. These findings can be used by clinicians and researchers for early intervention programmes.

The role of anxiety sensitivity in reactivity to trauma cues in treatment-seeking adults with substance use disorders

BACKGROUND

Exposure to traumatic events and posttraumatic stress disorder (PTSD) are common among individuals with substance use disorders (SUDs). Although the presence of trauma exposure and/or PTSD among those with SUDs is associated with a range of negative outcomes, much remains to be understood about the factors contributing to these outcomes. Anxiety sensitivity (the tendency to respond fearfully to the signs and symptoms of anxiety) has been linked to greater PTSD symptoms and the use of substances to cope with PTSD symptoms, and is a promising factor for understanding the negative outcomes associated with co-occurring PTSD and SUDs.

METHODS

This study examined the association between anxiety sensitivity and trauma cue reactivity among 194 trauma-exposed patients with SUDs (27.3% met criteria for current PTSD). Participants completed ratings of negative affect and substance cravings prior to and after exposure to a personally-relevant trauma cue.

RESULTS

Results indicated that anxiety sensitivity was associated with greater emotional reactivity (but not craving reactivity) to the trauma cue; neither PTSD symptom severity nor PTSD diagnosis moderated these associations. PTSD symptom severity was associated with greater emotional and craving reactivity to the trauma cue.

CONCLUSIONS

Results highlight the potential utility of targeting anxiety sensitivity in treatments for trauma-exposed patients with SUDs with and without PTSD.

Rationale, design, and implementation of a clinical trial of a mindfulness-based relapse prevention protocol for the treatment of women with comorbid post traumatic stress disorder and substance use disorder

Comorbid post-traumatic stress disorder (PTSD) and substance use disorders (SUD) commonly co-occur and is associated with a more complex clinical presentation with poorer clinical outcomes when compared with either disorder alone, and untreated PTSD can predict relapse to substance abuse. A number of integrated treatment approaches addressing symptoms of both PTSD and SUD concurrently demonstrate that both disorders can safely and effectively be treated concurrently. However, attrition and SUD relapse rates remain high and there is need to further develop new treatment approaches. Innovative approaches such as mindfulness meditation (MM) successfully used in the treatment of SUD may offer additional benefits for individuals with SUD complicated with PTSD. Specifically, Mindfulness-based Relapse Prevention (MBRP) integrates coping skills from cognitive-behavioral relapse prevention therapy with MM practices, raising awareness of substance use triggers and reactive behavioral patterns, and teaching skillful coping responses. Here we present the design and methods for the "Mindfulness Meditation for the Treatment of Women with comorbid PTSD and SUD" study, a Stage 1b behavioral development study that modifies MBRP treatment to address both PTSD and SUD in a community setting. This study is divided into three parts: revising the existing evidence-based manual, piloting the intervention, and testing the new manual in a randomized controlled pilot trial in women with comorbid PTSD and SUD enrolled in a community-based SUD treatment program.

Trauma history is associated with prior suicide attempt history in hospitalized patients with major depressive disorder

Although the relationships between PTSD, abuse history, and suicidal behaviors are well-established in military and outpatient samples, little data is available on this relationship in inpatient samples. This study examines the relationships between these variables and related demographic and clinical correlates in a sample of psychiatric inpatients with a diagnosis of major depressive disorder using electronic medical record (EMR) data. Controlling for relevant demographic and clinical variables, PTSD diagnosis and history of abuse were both significantly associated with history of suicide attempt, but in a combined model, only history of abuse remained as a significant predictor. Whereas history of abuse was associated with a history multiple suicide attempts, PTSD diagnosis was not. Both insurance status and gender acted as significant moderators of the relationship between history of abuse and history of suicide attempt, with males and those with public/no insurance having greater associations with history of suicide attempts when an abuse history was present. These data indicate the importance of documentation of PTSD, abuse history, and history of suicide attempts. The results also suggest that in the presence of an abuse history or PTSD diagnosis, additional time spent on safety and aftercare planning following hospital discharge may be indicated.

The mediating role of sleep disturbances in the relationship between posttraumatic stress disorder and self-injurious behavior

Although posttraumatic stress disorder (PTSD) is associated with self-injurious behavior, it is currently unclear what mechanisms may account for this relationship. Sleep disturbances may be relevant as they are common among those with PTSD and are associated with emotion regulation difficulties, which may increase vulnerability to self-injurious behavior. As such, we investigated the relationship between PTSD and self-injurious behaviors, and the mediating roles of nightmares and insomnia. Hypotheses were tested cross-sectionally in a sample of psychology clinic outpatients (N=255). Participants completed a structured clinical interview assessing PTSD and self-report questionnaires measuring insomnia, nightmares, and self-injurious behaviors (i.e., Have you ever cut, burned, or scratched yourself on purpose?). PTSD was associated with self-injurious behavior after covarying for depression, and nightmare severity mediated the relationship between PTSD and self-injurious behavior. Findings are consistent with research indicating that sleep disturbances, specifically nightmares, are important predictors of poor outcomes among those with PTSD, and extend this research to suggest their role in self-injurious behaviors as well.

Community-based strategy to prevent deliberate self-harm in adolescence: an inquiry to find risk factors at school

BACKGROUND

Self-harm behaviors consist of parasuicidal behaviors, which represent "a deliberate destruction of body tissue, with or without suicidal intent". A theoretical model is the Experiential Avoidance Model. The most frequent risk factors are school distress, poor social integration, poor social and family support, drugs use, sexual abuse, altered sense of life and death, bad relationship with the body and unsolved body mentalization process.

OBJECTIVES

The objective of the present study was to perform an analysis of risk factors for self-harm behaviors, to help plan preventive actions.

PATIENTS AND METHODS

One questionnaire with specific scales was employed for students, whereas three semi-structured interviews were employed for teachers, all on distress perception and self-harm in school.

RESULTS

Data analysis confirms an association between self- cutting and alcohol use, sexual harassments, school dropout, threatening people, incommunicability with family members and negative relationship with the body and suicide attempts, with a clear tendency for males. In the interviews, teachers highlight self-injury as a dysfunctional relationship with the body and observe several risk markers of psychological distress.

CONCLUSIONS

The results confirm the available literature data, while noting that self-harming is a preponderantly male behavior. The results also signal the need to create opportunities to instruct teachers to combat the resistances and stereotypes of psychological distress.

Deliberate self-harm and the nexus of violence, victimization, and mental health problems in the United States

Deliberate self-harm (DSH) is associated with diverse psychiatric diagnoses and broad psychopathology but less is known about its association with other forms of interpersonal violence and crime. Using the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), the current study examined linkages between not only DSH and mental health and substance abuse comorbidity, but also childhood abuse, lifetime victimization, and a variety of violent behaviors. We identified a prevalence of 2.91% for DSH and found that DSH is associated with generalized and severe psychopathology, wide-ranging substance abuse, and adverse childhood experiences. Contrary to other studies, we found significant racial and ethnic differences in DSH. African-American, Latinos, and Asians, were substantially less likely than Whites to report DSH. Our hypothesis that DSH would be associated with a variety of violent behaviors including robbery, intimate partner violence, forced sex, cruelty to animals, and use of a weapon was supported even after adjusting for an array of covariates. We extend previous research on DSH by examining its prevalence in one the largest comorbidity surveys ever conducted and show that DSH is associated with multiple forms of violent behavior toward others, including animals.

PTSD and reasons for living: associations with depressive symptoms and alcohol use

Posttraumatic stress disorder (PTSD) is associated with suicidal ideation and behavior, and is found to frequently co-occur with other conditions that exacerbate the risk for suicidal behavior. Despite these findings, few individuals with PTSD engage in suicidal acts, and there has been little research to examine those factors that protect against such behaviors. The current study used path analysis to examine the association among PTSD, depression, hazardous alcohol consumption, and beliefs about suicide (i.e., reasons for living) in a community sample with motor vehicle accident related-PTSD (N=50). Reasons for living were inversely associated with PTSD, depression, and alcohol use. Further, depression symptom severity accounted for the association between PTSD symptom severity and reasons for living. In contrast, hazardous alcohol consumption only demonstrated a trend for accounting for the association between PTSD and reasons for living. Our findings highlight the importance of clinicians assessing co-occurring depression symptoms and suggest the potential use of interventions that promote adaptive cognitions about suicide among people with PTSD.

Self-injurious behaviors in posttraumatic stress disorder: an examination of potential moderators

BACKGROUND

Despite increasing evidence for a relation between posttraumatic stress disorder (PTSD) and self-injurious behaviors (SIB), limited research has examined the factors that may moderate the associations between PTSD and both nonsuicidal SIB (deliberate self-harm; DSH) and suicidal SIB (suicide attempts). Nonetheless, research suggests that characteristics of the traumatic event, co-occurring borderline personality disorder (BPD), and emotion dysregulation may influence the relations between PTSD and SIB.

METHODS

Thus, the aim of this study was to examine the moderating role of these factors in the association between PTSD and SIB (including history and frequency of DSH and suicide attempts, and DSH versatility) among a sample of substance use disorder inpatients with (n=116) and without (n=130) a history of PTSD.

RESULTS

Results from stepwise regression analyses indicate that sexual assault-related PTSD predicted suicide attempt frequency and DSH versatility among those with PTSD. Furthermore, results from hierarchical linear and logistic regression analyses suggest that co-occurring BPD moderates the relationship between PTSD and both DSH history and versatility and emotion dysregulation moderates the relationship between PTSD and DSH frequency. Specifically, the relations between PTSD and DSH outcomes were stronger among participants with co-occurring BPD and higher levels of emotion dysregulation.

LIMITATIONS

This study is limited by its reliance on cross-sectional, self-report data.

CONCLUSIONS

Despite limitations, findings suggest distinct risk factors for suicide attempts and DSH, and highlight the importance of examining characteristics of the trauma and associated BPD and emotion dysregulation in assessing risk for SIB in PTSD.

Childhood physical abuse, non-suicidal self-harm and attempted suicide amongst regular injecting drug users

BACKGROUND

Childhood physical abuse (CPA), non-suicidal self-harm and attempted suicide are all highly prevalent amongst injecting drug users (IDU). This paper reported on the association of CPA with self-harm and attempted suicide.

METHODS

Cross-sectional study, with 300 IDU administered a structured interview examining the prevalence of CPA, non-suicidal self-harm and suicide attempts.

RESULTS

CPA was reported by 74.3%, and severe CPA by 40.3%. A history of non-suicidal self-harm was reported by 23.7%, and 25.7% had attempted suicide. Non-suicidal self-harm preceded the suicide attempt in 83.3% of cases where both had occurred. Independent correlates of non-suicidal self-harm were: female gender (OR 3.62), avoided home due to conflict (OR 2.28) and more extensive polydrug use (OR 1.32). Independent correlates of attempted suicide were: severe CPA (OR 3.18), frequent CPA (OR 2.54), avoided home due to conflict (OR 3.95), female gender (OR 2.99), a positive screen for Conduct Disorder (OR 3.53), and more extensive polydrug use (OR 1.52).

CONCLUSIONS

Those presenting to treatment agencies are highly likely to have a history of CPA, that may still influence their behaviours. Screening for histories of CPA and non-suicidal self-harm appears warranted when determining suicide risk for this population. At the population level, reductions in the rate of CPA, could possibly reduce the rate of subsequent suicidality.

Posttraumatic stress and depression symptoms as correlates of deliberate self-harm among community women experiencing intimate partnerviolence

Deliberate self-harm (DSH) among women in the general population is correlated separately with posttraumatic stress, depression, and abuse during childhood and adulthood. The prevalence of these DSH correlates is particularly high among women exposed to intimate partner violence (IPV), yet few studies have examined DSH among this high-risk population and none have examined these correlates simultaneously. Two hundred and twelve IPV-victimized women in the community participated in a 2-h retrospective interview. One-third reported current or past DSH. Discriminant analysis was used to examine which posttraumatic stress and depression symptoms and types of current IPV and childhood abuse were uniquely associated with current DSH. Findings show that women who currently use DSH reported greater severity of posttraumatic stress numbing symptoms and more severe sexual IPV compared to women who used DSH only in the past. Examining factors that are associated with women's current DSH in this population is critical so that a focus on DSH can be integrated into the treatment plans of women who are receiving mental health care, but also so that women who are not receiving such care can be referred to adequate mental health services.

Exploring the relationship between posttraumatic stress disorder and deliberate self-harm: the moderating roles of borderline and avoidant personality disorders

Despite increasing evidence for an association between posttraumatic stress disorder (PTSD) and deliberate self-harm (DSH), few studies have examined the factors that moderate this association or the impact of co-occurring personality disorders among individuals with PTSD on DSH frequency. Given the high rates of co-occurrence between PTSD and two personality disorders of particular relevance to DSH, borderline personality disorder (BPD) and avoidant personality disorder (AVPD), this study examined the moderating role of these personality disorders in the association between PTSD and DSH frequency among a sample of substance use disorder patients (N=61). Patients completed structured clinical interviews assessing PTSD, BPD, and AVPD and a questionnaire assessing DSH. Results revealed more frequent DSH among patients with (vs. without) PTSD and provided evidence for the moderating role of AVPD in this association. Specifically, results revealed heightened levels of DSH only among PTSD patients with co-occurring AVPD. Findings are consistent with past research demonstrating that the presence of co-occurring AVPD among patients with other Axis I and II disorders is associated with worse outcomes, and highlight the importance of continuing to examine the moderating role of AVPD in the association between PTSD and a variety of health-risk behaviors.

The moderating role of distress tolerance in the relationship between posttraumatic stress disorder symptom clusters and suicidal behavior among trauma exposed substance users in residential treatment

The co-occurrence of posttraumatic stress disorder (PTSD) and substance use disorders (SUDs) is associated with greater risk for suicidal behavior than either disorder alone. Research highlights the relevance of PTSD symptoms in particular to suicide risk within this population. Research has also provided support for an association between distress tolerance (DT) and both PTSD symptoms and suicidal behavior. This study examined the role of DT in the relationship between PTSD symptom severity and suicidal behavior in a sample of 164 SUD inpatients with a history of Criterion A traumatic exposure. Results indicated that DT moderated the relationship between PTSD symptoms (overall, re-experiencing, and hyperarousal) and medically attended suicide attempts, with the magnitude of the relationship increasing at higher levels of DT.

Intergenerational child abuse and coping

Many studies have investigated the consequences of child sexual abuse (CSA) but few have examined the intergenerational effects of poly- victimization and maladaptive coping. The purpose of this investigation was to examine patterns of maltreatment and maladaptive coping among second-generation CSA survivors. It is hypothesized that: (a) maternal CSA history would be associated with a higher incidence of poly-victimization and maladaptive coping and (b) experiencing more forms of abuse would mediate the relation between maternal CSA history and maladaptive coping behaviors. The method used was a chart review of 139 sexually abused females aged 12 to 17, examining maternal abuse history, maladaptive coping behaviors, and child maltreatment. The results showed that poly-victimization differed as a function of maternal CSA history but maladaptive coping did not. Experiencing more types of abuse was associated with both self-injurious behaviors and substance use. In conclusion, results support the hypothesis that second generation CSA survivors are more likely to experience poly-victimization. Future research should address how intergenerational patterns of abuse might affect presenting symptomatology and treatment outcome.

Self-mutilative behaviours in male alcohol-dependent inpatients and relationship with posttraumatic stress disorder

The aim of this study was to investigate the relationship between self-mutilation (SM) and posttraumatic stress disorder (PTSD) in male alcohol-dependent inpatients, and to examine whether there is something unique about self-mutilaters with the PTSD/alcohol-dependence co-morbidity, compared with self-mutilaters without PTSD in this population. Participants were 156 consecutively admitted male alcohol-dependent inpatients. Patients were investigated with the Self-mutilative Behaviour Questionnaire (SMBQ), the Traumatic Experiences Checklist (TEC), the Clinician Administered PTSD Scale (CAPS), the Symptom Checklist-Revised (SCL-90-R) and the Michigan Alcoholism Screening Test (MAST). Among alcohol-dependent inpatients, 34.0% (n=53) were considered as group with SM. Rate of being unemployed, history of any trauma, history of suicide attempt and lifetime PTSD diagnosis were higher, whereas being married, current age, age at onset of regular alcohol use and duration of education were lower in the group with SM. Mean scores of SCL-90 subscales, TEC and MAST were higher in the SM group. Although SM might be related with PTSD among male alcohol-dependent inpatients, predictors of SM were age at onset of regular alcohol use, history of suicide attempt, anxiety, depression and hostility. Age at onset of regular alcohol use, history of suicide attempt, anxiety, depression and somatisation predicted SM in the subgroup of patients without PTSD, whereas hostility predicted SM alone in the subgroup of patients with PTSD. Results support the anti-suicide and the affect-regulation models of SM in the non-PTSD group, whereas they support the hostility model of SM in the subgroup with PTSD in alcohol-dependent inpatients. Thus, to reduce self-mutilative behaviour (SMB)among alcohol-dependent patients, clinicians must address different subjects in different subgroup patients; that is, focussing hostility in those with PTSD co-morbidity.

Risk factors for suicidal ideation in a population of community-recruited female cocaine users

INTRODUCTION

Suicide, as the 11th leading cause of death in America, is a significant public health concern. Previous studies have shown that drug users are a population at especially high risk for suicidal ideation (SI). Although most people who think about killing themselves do not ultimately commit suicide, identifying those at risk for such thoughts is important.

METHODS

In this analysis, data from a sample of 462 cocaine-using women (87% African American) recruited using street outreach methods for a National Institute on Drug Abuse-funded study were examined to identify risk factors for lifetime SI. Sociodemographic factors, adverse childhood experiences, sexual behaviors, psychiatric comorbidities, and drug abuse and dependence were examined as potential risk factors using both bivariate and logistic regression analysis.

RESULTS

Fifty percent of the sample met at least one criterion for lifetime SI, and 32% of the sample reported a lifetime suicide attempt. In the final logistic regression model, childhood physical abuse, childhood sexual abuse, rape after the age of 15 years, posttraumatic stress disorder, and number of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, depression criteria met emerged as significant independent predictors of lifetime SI.

CONCLUSION

These findings identify important risk factors for SI among female substance abusers in community settings.

The Relationship Between Emotion Dysregulation and Deliberate Self-Harm Among Inpatients with Substance Use Disorders

Despite the emphasis on the role of emotion dysregulation in deliberate self-harm (DSH), no studies have examined this association among patients with substance use disorders (SUD). This study examined if emotion dysregulation is heightened among SUD inpatients with (vs. without) DSH, and if the association between DSH and emotion dysregulation remains significant when controlling for their shared association with risk factors for both, including borderline personality disorder (BPD), posttraumatic stress disorder (PTSD), childhood abuse, and substance use severity. Findings indicate heightened emotion dysregulation among SUD patients with (vs. without) DSH, and provide evidence of a unique association between emotion dysregulation and DSH when controlling for BPD, PTSD, childhood abuse, and substance use severity. Findings also highlight the particular relevance of three dimensions of emotion dysregulation to DSH among SUD patients: limited access to effective emotion regulation strategies, difficulties engaging in goal-directed behaviors when distressed, and emotional nonacceptance.

Attempted suicide, self-harm, and violent victimization among regular illicit drug users

Relationships among attempted suicide, nonsuicidal self-harm, and physical assault were examined in 400 regular users of heroin and/or psychostimulants. Twenty-eight percent had episodes of nonsuicidal self-harm, 32% had attempted suicide, and 95% had been violently assaulted. The number of suicide attempts and nonsuicidal self-harm incidents were correlated (ρ = 0.44). There were also significant correlations between the number of assaults and nonsuicidal self-harm incidents (ρ = 0.17), and suicide attempts (ρ = 0.27). The mean age onset for non-suicidal self-harm (18.9 yrs) was significantly younger than that of initial suicide (22.3 yrs). The age at initial physical assault (16.0yrs) was significantly younger than that of nonsuicidal self-harm and initial suicide attempt. Screening for all forms of violence appears warranted when determining suicide risk for this population.

The association of trauma and PTSD with the substance use profiles of alcohol- and cocaine-dependent out-of-treatment women

The association of trauma and posttraumatic stress disorder (PTSD) with alcohol and cocaine use is explored to determine if there is additive risk associated with dual dependence. Data were collected from out-of-treatment women enrolled in an HIV-prevention study. Women who experienced a DSM-IV qualifying event (n = 791) were stratified into four substance use groups based on lifetime alcohol and cocaine use. Women with lifetime comorbid alcohol and cocaine dependence experienced significantly more traumatic events and had a higher prevalence of violent events and lifetime diagnosis of PTSD and PTSD-related impairment. There is added risk for associated trauma and subsequent PTSD among women who have dual substance dependence. 

Investigating the co-occurrence of self-mutilation and suicide attempts among opioid-dependent individuals

The prevalence and risk factors associated with self-mutilation among opioid dependent cases and controls were determined, and the co-occurrence of self-mutilation and attempted suicide was examined. The prevalence of self-mutilation among cases and controls did not differ significantly (25% vs. 23%, respectively), with gender differences identified among cases only. A number of risk factors were found to be associated with self-mutilation, including borderline personality disorder, alcohol dependence, childhood sexual abuse, and multiple suicide attempts. Not only is self-mutilation a clinically significant problem, but when combined with a history of attempted suicide, the psychological dysfunction observed is markedly high.

Post-traumatic stress disorder and suicide risk: a systematic review

There is a gap in the literature regarding suicide risk among traumatized individuals with post-traumatic stress disorder (PTSD) and this article aims to systematically review literature on the relationship between PTSD and suicidal behavior and ideation. A meta-analysis of 50 articles that examined the association between PTSD and past and current suicidal ideation and behavior was conducted. There was no evidence for an increased risk of completed suicide in individuals with PTSD. PTSD was associated with an increased incidence of prior attempted suicide and prior and current suicidal ideation. Controlling for other psychiatric disorders (including depression) weakened, but did not eliminate, this association. The evidence indicates that there is an association between PTSD and suicidality with several factors, such as concurrent depression and the pre-trauma psychiatric condition, possibly mediating this relationship. There are significant clinical implications of the reported relationship for suicide risk assessment and therapy, and further studies might help to understand the mediating pathways between PTSD and increased suicide risk.

Deliberate self-harm and suicide in adolescents

Deliberate self-harm (DSH) is a widespread yet often hidden problem in adolescents and young adults. Though most DSH can be classified as "non-suicidal self-cutting", some do go on to commit suicide. In this paper, deliberate self-harm is examined, including its prevalence, etiology, management, and future research directions using self-cutting and self-burning as examples. This article reviews recent literature to help understand what is known about self-cutting behavior and its potential relationship to suicide as well as provide direction for research. Research shows that different ecological factors at the individual, family, peer, and societal levels are related to deliberate self-harm. Although there is an association between some self-injurers and drug abuse (including alcohol abuse) as well as eating disorders, there are various subgroups of self-cutters and most are not at high risk for suicide. However, all acts of self-injury should be taken seriously by health care professionals and comprehensive therapy offered to any adolescent with a history of DSH. Future research directions on deliberate self-harm are also discussed.

Risk factors and correlates of deliberate self-harm behavior: a systematic review

OBJECTIVE

Deliberate self-harm behavior--without suicidal intent--is a serious health problem and may be studied as a clinical phenomenon in its own right. Empirical studies of sociodemographic and psychological correlates and risk factors are systematically reviewed.

METHODS

We searched Medline, PsycINFO, PSYNDEX (German psychological literature), and reference lists. We targeted self-induced bodily harm without conscious suicidal intent. Studies on suicidal behavior or self-poisoning were only included if they also assessed nonsuicidal self-harm.

RESULTS

Fifty-nine original studies met the criteria. Deliberate self-harm may occur at all ages, yet adolescents and young adults are at a higher risk. Evidence on gender is complex. Only 5 studies realize a prospective design (6 months to 10 years) and test predictors. The majority use cross-sectional and retrospective methods. No longitudinal study (separately) examines new incidence. Evidence of correlates encompasses distal/proximal, person/environment, and state/trait factors. Many studies report associations between current self-harm behavior and a history of childhood sexual abuse. Adolescent and adult self-harmers experience more frequent and more negative emotions, such as anxiety, depression, and aggressiveness, than persons who do not self-harm. Two studies yield specific interactions between childhood trauma and current traits and states such as low emotional expressivity, low self-esteem, and dissociation with respect to a vulnerability to self-harm.

CONCLUSION

Evidence of distal, biographical stressors is fairly strong. Proximal stressors have rarely been investigated; protective factors, hardly at all. Despite many findings of correlates, the data do not yet justify terming them risk factors. Longitudinal studies are needed.

A typology of heroin-dependent patients based on their history of self-injurious behaviours

Self-injurious behaviours (SIB) can provide useful criteria for subtyping heroin-dependent patients, since SIB have been related to an opioid system dysfunction and they hinder patient management. The frequency of nine varieties of moderate/superficial SIB during active heroin use was assessed retrospectively in 164 heroin-dependent patients. A principal component analysis of SIB episodes revealed a four-component solution which accounted for 69.3% of the variance. The components were named as follows (percentage of variance explained by each component is enclosed in parentheses): 'SIB with objects' (27.3%), 'SIB by biting/scratching/hair-pulling' (18.2%), 'SIB by hitting' (12.3%), and 'SIB by picking scabs' (11.5%). A cluster analysis using the results of the principal component analysis enabled us to define three types of heroin-dependent patients, labelled: 'low-occurrence SIB cluster' (59.8%), 'high-occurrence scab-picking cluster' (31.7%) and 'high-occurrence hitting and cutting cluster' (8.5%). SIB by hitting was the most discriminatory component among clusters: its frequency was at a minimum in the low-occurrence SIB cluster, and attained a maximum in the high-occurrence hitting and cutting cluster. However, there were no differences among clusters regarding heroin-use variables. Patients from the low-occurrence SIB cluster, compared with those from the other two clusters, reported fewer episodes of SIB or suicide attempts and were diagnosed less frequently with bulimia. Patients from the high-occurrence scab-picking cluster had a very frequent history of these SIB, while the opposite was true in patients from the high-occurrence hitting and cutting cluster. Patients from this cluster probably presented staff members with the main management problems.

The effect of posttraumatic stress disorder on risk-taking propensity among crack/cocaine users in residential substance abuse treatment

BACKGROUND

The co-occurrence of posttraumatic stress disorder (PTSD) and substance use disorders (SUDs) has been found to be associated with a range of negative clinical outcomes (e.g., relapse, suicide, legal problems, HIV infection). However, less is known about the particular factors that may be placing individuals with a co-occurring PTSD and SUD diagnosis at risk for these outcomes. The construct of risk-taking propensity may hold particular promise.

METHODS

To investigate the relevance of risk-taking propensity to PTSD-SUD patients, differences in risk-taking propensity were examined among 90 crack/cocaine dependent patients in residential substance abuse treatment with (n=20) or without (n=70) a current PTSD diagnosis. Risk-taking propensity was assessed using an established behaviorally based measure, the Balloon Analogue Risk Task (BART).

RESULTS

Crack/cocaine dependent patients with PTSD exhibited significantly greater levels of risk-taking propensity than patients without PTSD, and this difference remained significant even when controlling for the presence of comorbid psychiatric disorders and current psychotropic medication use. No evidence was found for a different pattern of change in risk-taking propensity from the beginning to the end of the task as a function of PTSD status.

CONCLUSIONS

Although preliminary, results suggest the need to further investigate risk-taking propensity as a factor that may be associated with the negative clinical outcomes observed among crack/cocaine users with PTSD.

Substance use, post-traumatic stress disorder and violence

PURPOSE OF REVIEW

The present review focuses on the co-occurrence of substance use disorder and post-traumatic stress disorder, with special attention to measurement and the role of violence as a contributor to the comorbidity.

RECENT FINDINGS

Symptoms of post-traumatic stress disorder in the presence or absence of a post-traumatic stress disorder diagnosis are comorbid with several substance use dependencies and with a range of severity of substance use.

SUMMARY

Lack of consistency in terms of substance use classification and measurement of post-traumatic stress disorder across studies continues to hinder comparisons of rates of comorbid substance use disorder and post-traumatic stress disorder. More attention to the role of violence as a contributor to the comorbidity and its impact on treatment outcomes is warranted.

Anxiety disorders and suicidal behaviour: an update

PURPOSE OF REVIEW

The primary aim of this review is to present the main findings from the literature published between January 2006 and May 2007 on anxiety and suicidal behaviour. The secondary aim is to present critical comments on methodological issues, highlighting areas for future research.

RECENT FINDINGS

Traditionally, anxiety disorders have not been viewed as independent risk factors for suicidal behaviour, and therefore assessment of anxiety disorders has not been particularly emphasized in clinical enquiries and suicide screening tools. This review identifies evidence suggesting that specific anxiety disorders (e.g. generalized anxiety disorder, panic disorder and obsessive-compulsive disorder) may be independently associated with suicidality, to which they particularly contribute when they are co-morbid with bipolar disorder, depression, schizophrenia, or post-traumatic stress disorder, in both child/adolescent and adult populations.

SUMMARY

Despite methodological issues preventing firm conclusions from being drawn in most cases, these findings should prompt clinicians to evaluate more specifically the impact of anxiety disorders on suicidal behaviour, particularly when they are co-morbid. Further research into treatment of anxiety disorders in relation to preventing suicide is required.

Relationships between suicide risk, traumatic experiences, and substance use among juvenile detainees

Youth suicide ideation in juvenile justice settings is a phenomenon with multiple determinants. This article examines relationships among determinants of suicidal ideation utilizing various screening instruments. Consecutive youth admitted to detention in Connecticut (N = 757) completed the Massachusetts Youth Screening Instrument 2 (MAYSI-2), the Suicidal Ideation Questionnaire (SIQ), measures of substance use, and risk and protective factors for violence during intake screening. In bivariate and multivariate analyses (controlling for demographic and MAYSI-2 sub-scale scores), relationships were found between the Traumatic Experiences and Alcohol and Drug Use subscales of the MAYSI-2 and the SIQ. The potential impact of traumatic stress and substance use symptoms in understanding and detecting youths who are at risk for suicide is discussed.