Posttraumatic Stress Disorder Symptom Clusters and Acquired Capability for Suicide: A Reexamination Using DSM-5 Criteria

Acquired Capability for Suicide: An Evolutionary Concept Analysis

While virtually all suicide attempters experience ideations, not all who think about suicide will attempt or die by suicide. The ideation-to-action framework has led to new theories distinguishing suicide ideators from suicide attempters. The framework suggests that suicide progresses on a spectrum of thoughts and behaviors with different identifiers and explanations. The concept of acquired capability for suicide (ACS), conceptualized by the Interpersonal Psychological Theory of Suicide, is the first to explain the movement from ideation to action. This concept analysis of ACS is timely and relevant for greater clarification of the role ACS has in the movement from ideation to action. Rodgers' evolutionary concept analysis method is used. The six-step evolutionary method highlights the concept's attributes, antecedents, and consequences and provides a basis for further inquiry and development rather than a final definition.

A systematic review of the relationship between death anxiety, capability for suicide, and suicidality

This systematic review aimed to examine the relationship between death anxiety and suicidality in adults, and the impact of death anxiety interventions on the capability for suicide and suicidality. MEDLINE, PsycINFO, PubMed, and Web of Science were extensively searched using purpose-related keywords from the earliest to July 29th, 2022. A total of 376 participants were included across four studies which met inclusion. Death anxiety was found to relate significantly and positively with rescue potential, and although weak, negatively with suicide intent, circumstances of attempt, and a wish to die. There was no relationship between death anxiety and lethality or risk of lethality. Further, no studies examined the effects of death anxiety interventions on the capability for suicide and suicidality. It is imperative that future research implements a more rigorous methodology to establish the relationship between death anxiety and suicidality and establish the impacts of death anxiety interventions on the capability for suicide and suicidality.

Prospective examination of pre-trauma anhedonia as a risk factor for post-traumatic stress symptoms

BACKGROUND

Anhedonia, the reduction of pleasure and reward-seeking behaviour, is a transdiagnostic symptom with well-described neural circuit mediators. Although typically observed during disease state, extant hypotheses suggest that anhedonia may also be an early risk factor for development of psychopathology. Understanding the contribution of anhedonia to the trauma-response trajectory may bolster inferences about biological mechanisms contributing to pre-trauma risk versus trauma-related symptom expression, knowledge of which could aid in targeted interventions.

OBJECTIVE

Using a prospective, longitudinal design in a population at risk for trauma disorders, we tested the hypothesis that anhedonia may be a pre-trauma risk factor for post-traumatic stress disorder (PTSD) symptoms.

METHODS

Adult male participants from the Marine Resilience Study (N = 2,593) were assessed across three time-points (pre-deployment, 3-month and 6-month post-deployment). An anhedonia factor was extracted from self-report instruments pre-trauma and tested for its relationship with development of PTSD re-experiencing symptoms after deployment.

RESULTS

Higher pre-deployment anhedonia predicted increased PTSD intrusive re-experiencing symptoms at 3- and 6-months post-deployment when controlling for pre-trauma PTSD and depression symptoms. Depression symptoms were not significant predictors of subsequent PTSD intrusive re-experiencing symptoms. Anhedonia at 3 mo also robustly predicted maintenance of PTSD intrusive re-experiencing symptoms at the 6 mo time point.

CONCLUSIONS

Pre-deployment anhedonia may be a pre-trauma risk factor for PTSD, not simply a state-dependent effect of trauma exposure and PTSD symptom expression. Anhedonia may contribute to persistence and/or chronicity of re-experiencing symptoms after the emergence of PTSD symptoms.

PTSD and Suicidal Behaviors Amongst L'Aquila 2009 Earthquake Young Survivors

Background: Post-traumatic stress disorder (PTSD) is one of the most frequent and severe psychiatric consequences of natural disasters, frequently associated with suicidality. The aim of this study was at examining the possible relationships between suicidal behaviors and full-blown or partial PTSD, in a sample of young earthquake survivors. The second aim was at investigating the specific role of PTSD symptoms on suicidality. Methods: A total of 475 young adults who survived the L'Aquila 2009 earthquake, one of the most severe Italian disasters of the last decades, were recruited and assessed after 21 months from the catastrophe. Participants were evaluated by two questionnaires assessing subthreshold psychopathology, the Trauma and Loss Spectrum Self-Report (TALS-SR) to investigate both full and partial PTSD, and two specific Mood Spectrum Self-Report (MOODS-SR) sub-domains exploring suicidality, namely suicidal ideation and suicide attempts. Results: The ensuing findings showed that suicidal ideation and suicide attempts were present, respectively, in 40 (8.4%) and 11 (2.3%) survivors. Rates of suicidal ideation were significantly more elevated in full-blown PTSD subjects (group 1), as compared with those suffering from partial (group 2) or no PTSD (group 3). Interestingly, group 2 subjects showed significantly more suicidal ideation than healthy individuals, and less than those of group 1, while the frequency of suicide attempts was similar across the three groups. Suicidal ideation was associated with higher scores in the following TALS-SR domains: grief-reactions, re-experiencing, avoidance and numbing, maladaptive coping, and personal characteristics/risk factor. Conclusions: The results of the present study support and extend previous findings on the role of PTSD symptoms in suicidality after a severe earthquake. However, as compared with available literature, they also highlight the significant impact of sub-threshold PTSD manifestations in increasing the suicide risk in survivors of a mass disaster.

Multimodal structural neuroimaging markers of risk and recovery from posttrauma anhedonia: A prospective investigation

BACKGROUND

Anhedonic symptoms of posttraumatic stress disorder (PTSD) reflect deficits in reward processing that have significant functional consequences. Although recent evidence suggests that disrupted integrity of fronto-limbic circuitry is related to PTSD development, including anhedonic PTSD symptoms (posttrauma anhedonia [PTA]), little is known about potential structural biomarkers of long-term PTA as well as structural changes in fronto-limbic pathways associated with recovery from PTA over time.

METHODS

We investigated associations between white matter microstructure, gray matter volume, and PTA in 75 recently traumatized individuals, with a subset of participants (n = 35) completing follow-up assessment 12 months after trauma exposure. Deterministic tractography and voxel-based morphometry were used to assess changes in white and gray matter structure associated with changes in PTA.

RESULTS

Reduced fractional anisotropy (FA) of the uncinate fasciculus at around the time of trauma predicted greater PTA at 12-months posttrauma. Further, increased FA of the fornix over time was associated with lower PTA between 1 and 12-months posttrauma. Increased gray matter volume of the ventromedial prefrontal cortex and precuneus over time was also associated with reduced PTA.

CONCLUSIONS

The microstructure of the uncinate fasciculus, an amygdala-prefrontal white matter connection, may represent a biomarker of vulnerability for later PTA. Conversely, development and recovery from PTA appear to be facilitated by white and gray matter structural changes in a major hippocampal pathway, the fornix. The present findings shed new light on neuroanatomical substrates of recovery from PTA and characterize white matter biomarkers of risk for posttraumatic dysfunction.

Associations between moral injury, PTSD clusters, and depression among Israeli veterans: a network approach

Background: Moral Injury (MI) is one of the adverse consequences of combat. Following exposure to potentially morally injurious events (PMIEs)--events perceived as violations of deep moral beliefs by oneself or trusted individuals--a significant minority of veterans could develop posttraumatic stress disorder (PTSD) and depression. Objective: The current study represents the first attempt to apply a network analysis model to examine an exploratory empirical conceptualization of a network of PMIEs during military service, post-traumatic stress disorder (PTSD) symptom clusters, depression, and combat exposure among Israel Defence Forces veterans. Method: A volunteer sample of 191 Israeli combat veterans were recruited during 2017, and completed validated self-report questionnaires tapping PMIEs, PTSD, and depression in a cross-sectional design study. A regularized Gaussian graphical model was estimated. Results: Network analysis revealed strong bridge associations between the PTSD nodes and most of the PMIEs nodes. The nodes of PMIE-betrayal and PTSD negative alterations in cognitions and mood (NACM) symptom cluster were found to have a bridging function between other PMIEs and PTSD. Depression was found to be connected to most of the PMIEs and PTSD nodes. Conclusions: The study's findings offer an overview of the complex relationships between PMIEs and PTSD clusters among Israeli veterans. PMIEs--notably, betrayal-based experiences--are related to PTSD clusters directly and through depressive symptoms. Some possible mechanisms for the links between PMIEs and PTSD and the clinical implications related to specific interventions are discussed.

Structural connectivity and risk for anhedonia after trauma: A prospective study and replication

Anhedonia emerges in some people after psychological trauma, reflected by a loss of interest, diminished affect, and detachment. Structural abnormalities in specific neural pathways at the time of trauma may influence the development of these posttraumatic anhedonia (PTA) symptoms. In this prospective study, we determined whether white matter connectivity at around one month post-trauma predicts PTA and other PTSD symptoms at six months post-trauma. Thirty men and women aged 19-62 were recruited from the emergency department of a Level I trauma center. Participants received diffusion tensor imaging at approximately one month post-trauma and clinical assessments at one and six months post-trauma. Probabilistic tractography was used to examine connectivity of select pathways. A replication sample (N = 57) in an independent, cross-sectional dataset of traumatized women was similarly analyzed. Logistic regression results indicated that, after accounting for early PTSD symptoms (at one month) and other clinical risk factors, the integrity of the uncinate fasciculus (UF) uniquely predicted the presence of PTA at six months post-trauma (Beta = -225.6, p < .05). Together, these factors contributed to 76% of the variance in PTA. Integrity of the UF also predicted re-experiencing PTSD symptoms at six months post-trauma. These results were supported in our replication analyses. Our findings indicate that the integrity of the UF around 1 month post-trauma affects vulnerability for the development of anhedonic PTSD symptoms as well as re-experiencing symptoms. Connectivity of this amygdala-ventromedial prefrontal pathway appears to be a salient predictor of anhedonia, above and beyond clinical risk factors.

Can Anhedonia Be Considered a Suicide Risk Factor? A Review of the Literature

Background and Objectives: At present, data collected from the literature about suicide and anhedonia are controversial. Some studies have shown that low levels of anhedonia are associated with serious suicide attempts and death by suicide, while other studies have shown that high levels of anhedonia are associated with suicide. Materials and Methods: For this review, we searched PubMed, Medline, and ScienceDirect for clinical studies published from 1 January 1990 to 31 December 2018 with the following search terms used in the title or in the abstract: “anhedonia AND suicid*.” We obtained a total of 155 articles; 133 items were excluded using specific exclusion criteria, the remaining 22 articles included were divided into six groups based on the psychiatric diagnosis: mood disorders, schizophrenia spectrum disorders, post-traumatic stress disorder (PTSD), other diagnoses, attempted suicides, and others (healthy subjects). Results: The results of this review reveal inconsistencies. Some studies reported that high anhedonia scores were associated with suicidal behavior (regardless of the diagnosis), while other studies found that low anhedonia scores were associated with suicidal behavior, and a few studies reported no association. The most consistent association between anhedonia and suicidal behavior was found for affective disorders (7 of 7 studies reported a significant positive association) and for PTSD (3 of 3 studies reported a positive association). In the two studies of patients with schizophrenia, one found no association, and one found a negative association. For patients who attempted suicide (undiagnosed), one study found a positive association, one a positive association only for depressed attempters, and one a negative association. Conclusions: We found the most consistent positive association for patients with affective disorders and PTSD, indicating that the assessment of anhedonia may be useful in the evaluation of suicidal risk.

Does Anhedonia Presage Increased Risk of Posttraumatic Stress Disorder? : Adolescent Anhedonia and Posttraumatic Disorders

Anhedonia, the reduced ability to experience pleasure, is a dimensional entity linked to multiple neuropsychiatric disorders, where it is associated with diminished treatment response, reduced global function, and increased suicidality. It has been suggested that anhedonia and the related disruption in reward processing may be critical precursors to development of psychiatric symptoms later in life. Here, we examine cross-species evidence supporting the hypothesis that early life experiences modulate development of reward processing, which if disrupted, result in anhedonia. Importantly, we find that anhedonia may confer risk for later neuropsychiatric disorders, especially posttraumatic stress disorder (PTSD). Whereas childhood trauma has long been associated with increased anhedonia and increased subsequent risk for trauma-related disorders in adulthood, here we focus on an additional novel, emerging direct contributor to anhedonia in rodents and humans: fragmented, chaotic environmental signals ("FRAG") during critical periods of development. In rodents, recent data suggest that adolescent anhedonia may derive from aberrant pleasure/reward circuit maturation. In humans, recent longitudinal studies support that FRAG is associated with increased anhedonia in adolescence. Both human and rodent FRAG exposure also leads to aberrant hippocampal function. Prospective studies are underway to examine if anhedonia is also a marker of PTSD risk. These preliminary cross-species studies provide a critical construct for future examination of the etiology of trauma-related symptoms in adults and for and development of prophylactic and therapeutic interventions. In addition, longitudinal studies of reward circuit development with and without FRAG will be critical to test the mechanistic hypothesis that early life FRAG modifies reward circuitry with subsequent consequences for adolescent-emergent anhedonia and contributes to risk and resilience to trauma and stress in adulthood.