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Suicide Attempts Following Traumatic
Brain InjuryFrom Risk Identification to Prevention
Rolf B. Gainer, Ph.D.Neurologic Rehabilitation Institute of Ontario
Neurologic Rehabilitation Institute atBrookhaven Hospital
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Learning Objectives
• Identify psychiatric and psychological issues associated with suicidal behavior following TBI
• Identify risk factors related to suicide
• Develop an understanding of a multi-axial approach to assessment
• Identify methods to reduce risk and address suicidality
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by the numbers: 32,000 deaths per year, over 1 million
attempts 8.3 million seriously considered suicide this
past year Men are 4 times as likely to die by suicide
than women Veterans are 2 times as likely to die by
suicide than nonveterans Younger and older veterans at a higher risk
than middle-aged vets
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the geography of suicide risk
living in rural Nevada, Wyoming, Idaho, Oregon, New Mexico, Oklahoma, Montana, Alaska
11.6/100,000 in Rhode Island, New Jersey, Massachusetts
67.0/100,000 in Nevada being American Indian or Alaskan
Native, youth or middle-aged
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factors which set the stage for suicide
isolated from othershistory of abusehistory of traumasocio-cultural lossesdomestic violence
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Why Live?
• Confluence of negative feelings and self-directed anger
• Thinking about “the end”• Developing plans• Selecting method• Implementation phase
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The TBI Factors• Depression/ despair/
hopelessness• Pre-existing and co-morbid
psychiatric diagnosis• History of previous attempts• Family history of suicide• Substance abuse / addiction
history• Individuals with neurobehavioral
syndrome or seizure disorder at “enhanced risk”
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bringing a TBI home PTSD Physical and cognitive
disability Physical illness, ongoing
medical care Exposure to suicide by others Relationship changes Job loss/ financial problems
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a personal life in turmoil
lack of social support network
isolationbarriers to accessing carestigma of asking for help
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Setting the Stage• Depression over loss of
self and functional changes• Experience of despair• Feelings of worthlessness• History of ideation and
previous attempts, both pre- and post- TBI
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enhancing the risk
impulsive behaviors, limited self regulation
failed sense of belongingperceived burden on othersloss of fear of death and
pain
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“The Process” of Suicide
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Depression & Despair
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Life Not Worth Living
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Loss of Self
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Disconnecting
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Creating “The Plan”
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The Act: Lethal Impulse
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A Different Model for Suicide• Ready• Fire• Aim
• Role of impulsive behaviors• Executive Dysfunction• Thinking, planning, decision
making problems• Role of Mood state instability
• Ready• Aim • Fire
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Suicide and Cognition• “Thinking about
thinking”• Unable to withstand
impulse• “Getting stuck”
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A Model for Understanding Suicide
• Self worth vs. worthlessness• Hopelessness/depression/despair• Anger/Hostility• Plan• Method• Access• Previous history of suicidal thoughts
and attempts• Capacity to act on plan• Social withdrawal• In TBI cases, impulsivity is an
important factor
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Prevalence & Risk• 17% of individuals with TBI report
suicidal thoughts, plans and attempts in first 5 years (Teasdale, 2000)
• Majority are males ages 25-35 at the greatest risk
• Feelings of hopelessness a key factor• Comorbidity with psychiatric or
substance abuse diagnosis• Role of identity crisis and social
disruption (Klonoff and Tate, 1995)• Risk remains high for a 15 year period
following first attempt
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The Research
• Social Withdrawal Syndrome (Sugarman, 1999)
• Role of Affective Disorders (Morton and Wehman, 1995)
• Awareness of deficits (Prigatano, 1996)• Disinhibition Syndrome (Shulman, 1997)• TBI as a stressful life event (Frey, 1995)• Increased risk associated with Mild TBI,
psychiatric diagnosis and psychosocial disadvantage (Teasdale and Engberg, 2000)
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The Perfect Storm: TBI and Suicide
High rate of depression within 1 year of injury (53.1%)
Cognitive deficits affect problem solving
Impaired self-regulation Loss of social role Loss of social connections Disconnect from “rhythm of life” Substance abuse
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A Better Storm: TBI + PTSD
Co-occurrence rate of 44-47% PTSD rate increases with physical
injury PTSD rate increases with multiple
injuries Concussion group had 27% PTSD
rate TBI with Loss of Consciousness
had a 44% PTSD rate
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Second Suicide Attempt: Greater Risk
• Unipolar or bipolar depression and schizophrenia diagnosis have the highest risk for up to 31 years following the first attempt (Tidemalm, Swedish Cohort Study, BMJ 2008, DOI:10)
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Understanding the Second Attempt
11.8% of first attempters die by suicide, 87% within 1 year of the first attempt
Majority used the same methodology Methods with highest later risk: hanging;
drowning; jumping; cutting; poisoning 84% of psychotic individuals who
attempted suicide, died in a subsequent attempt
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Aggression• Trigger/Life Event• Perception of
Attack/Injury/Threat
• Anger• Impulsivity• External
Aggressive Act
Suicidal Act• Depression
following TBI• Perception of
Depression and Suicidal Ideation
• Suicidal Planning• Impulsivity• Suicidal Act
Aggression and Suicide
(Mann, The Neurobiology of Suicide and Aggression, 2000)
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Issues of Diagnosis and Suicide Potential
• Depression• Bipolar Disease/Manic Depression• Psychosis/Thinking disorder• Personality Disorders/Borderline
Personality• Seizure Disorders/Pre and Post-Ictal
Changes• Impulse Control Problems• Drug/alcohol abuse and addiction• Anger/Rage problems/ Episodic
Explosive Disorder• Relationship of suicidal act to other
aggressive acts
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Brain Injury and Suicide Risk: Issues
• History of prior attempts, pre- and post injury
• History of psychiatric illness, pre and post injury
• History of suicide in other family members
• Passive ideation without an active plan
• Role of disinhibition, including medication related problems
• Anger/emotional dysregulation
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Brain Injury Accelerates Psychiatric Conditions
• Thinking problems• Emotional response to injury
and disability• Difficulties with impulse control
and self-regulation• Role of memory problems• Compliance with treatment• Social withdrawal• Social role changes• Perceived failure
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Mood State and Behavioral Changes
• Pre-injury psychiatric problems exacerbated by TBI
• Emergence of new psychiatric symptoms post-injury
• Effect of psychosocial stressors
• Response to disability• Effectiveness of medication
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Impulse Control Issues• Limited ability to self-manage mood
state• Self-regulation of behavior is impaired• Problems in selecting behavioral
alternatives• “Stuck” or repetitive quality of behavior• Difficulty in expressing feeling/mood
problems to others• Anger management • Family and social role issues• Seizure related events, possible
“kindling”
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Trigger Events Humiliation Shame Despair Real or anticipated loss of
relationship Real or anticipated change in
financial status Real or anticipated change in
health status
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A Four Axis Approach to Evaluating Suicide Risk
• Suicide Probability Scale (SPS) John Cull and Wayne Gill, 1988
• SPS uses a four axis system• Hopelessness• Suicide Ideation• Negative self-evaluation• Hostility
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Hopeless Indicators
• Loneliness• Inability to change life• Problems doing things, initiation• Not important to others• Unable to meet expectations• Few friends• No future/no improvement• Perceived disapproval by others• Feeling tired/listless• Can’t find happiness
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Suicidal Ideation Indicators
• Punish others by suicide• Punish self• “Better off dead”• “Less painful to die then
living this way”• Thought of a plan/method• Think of suicide
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Negative Self Evaluation Indicators
• Not feeling like a worthwhile person
• Not feeling appreciated by others
• Not missed by others if dead• Things don’t go well• Not close to mother• Not close to father• Not close to significant other
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Hostility Indicators
• Anger/rage control, “gets mad easily”
• Impulsive acts• Angry feelings towards others• Feels isolated from others• Senses anger from others• Can’t find a job/activity that I
like
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Practical Aspects of the SPS
• Establishes scores in four domains• Compares score to “average” and
standard deviation• Combines raw score data into a
weighted T-score to define “probability”
• Ranks probability risk from mild to severe
• Considers major stressors/upsets over last two years, including past attempts in assessing risk potential
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Suicide Probability Scale (SPS)
• Predicts risk potential based on self-report of the individual to questions
• The four axis model provides relationship to dimensions of suicide
• Clinical importance/relevance of questions relates to risk factors
• Limited bias caused by age, gender or ethnicity
• Can be re-administered without practice learning bias
• Current mood state dependent
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Suicide Probability Scale (SPS)
• Axial approach provides an opportunity to assess potential for suicidal thinking, planning and acting
• Risk potential is assigned using data from the four domains of the scale
• Test questions relate to current emotional state
• Instrument supports, but does not replace a clinical interview and assessment
• Specific questions/response trigger “risk”
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Applying the Suicide Probability Scale to TBI
• Cognitive issues must be considered• Reading and comprehension support may
be required• The role of denial may effect score and
obscure certain risk factors• Impulsive behaviour(s) will accelerate risk
potential• Planning of suicide, including access and
method may be poorly organized, but risk potential may be high
• Passive issues may be significant to risk
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The Past, Present, and the Future
• History of prior attempts, pre- and post-injury
• History of psychiatric illness, pre- and post-injury
• Suicide in other family members• Passive ideation without plan• Role of disinhibition• Substance abuse, prescription
drug reaction• Anger/emotional dysregulation
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Risk Assessment Process
• Clinical assessment based on presentation of suicidal thoughts and plan and the individual’s current mental state
• Assessment must include current psychological/psychiatric issues and diseases, past history and psychological stressors
• Use of an assessment instrument will highlight issues, but cannot be used solely without a further assessment
• Current behavioral risk issues must be evaluated
• Prevalence of impulsive behaviors in individuals with TBI will enhance risk potential
• Lack of planning due to cognitive deficits does not exclude the individual from risk assignment
• Mood state issues must be considered
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Risk Assessment
• Current stressors and/or life changes
• Medication and its effects• Substance use/abuse• Specific problem(s) that the
individual cannot solve• Engagement in other self-harmful
behavior(s)
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TBI and Suicide: Shared Risk Factors
AgeGenderSubstance UsePsychiatric DisorderAggressive Behavior
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a clear and present danger
Threatening to hurt or kill self Looking for ways to kill self Seeking access to pills,
weapons Talking or writing about death,
dying or suicide
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Watch for the warning signs
Feeling hopeless Trapped, no
alternatives Increased
drug/alcohol use Dramatic mood
change Withdrawal
Anxiety, agitation Sleep problems,
too little or too much
Rage, anger, revenge
Reckless actions Lost purpose for
living
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Risk Identification Leads to Prevention
• Is there evidence of suicidal thinking or self-harm?
• Has the person experienced a loss of self-worth related to their disability?
• Is there evidence of depression, including vegetative symptoms?
• Is there a plan and/or method for the act?
• Is there a passive component?• Is there a past history of suicide
attempts?• Has anger or hostility increased in
response to internal or external events?
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Passive Suicide
• Feeling they would be “better off dead”
• “I wish I died in the accident”• “I wish God would take me away”• Feelings of loneliness and isolation• Need to punish self• Desire to punish others through
suicide• Exposure to risk or engagement in
risky behavior and activities
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The Role of High Risk Behaviors in Suicide Ideation and Acts
• Engagement in high risk behaviors can be the plan for suicide
• Plan may include motor vehicles, sport activities, fights, drug/alcohol use
• Individual may not see themselves as the “active participant” and may express that these activities provide “relief”
• History may include multiple accidents, overdoses, fights
• Impaired judgment may initiate plan and act
• Stress event may trigger attempt
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“Suicide by Cop”: Passive or Active?
• Setting up event to occur• Using law enforcement or military
action to stage event• Requires planning and capacity to
operate plan• Individual is resigned to
completing the event, no “fail safe” mechanism
• Unlikely to communicate plan to others
• High likelihood of other risk factors being present
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Prevention and Treatment Issues
• Use clinical interview and assessment to determine risk
• Refer to mental health professionals for emergency evaluation and care
• Refer to law enforcement to prevent person from moving forward with plan
• Avoid “contracting for safety” in situations where the person is outside of appropriate and immediate supervision
• Person may express relief or calm when a plan is established
• Maintain awareness of non-verbal behaviors and cues
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Prevention and Treatment Issues
• Maintain contact with the person, establish their location
• Keep them engaged/talking• Enlist help from another
person to contact mental health or law enforcement
• Avoid argument or confrontation
• Avoid value judgments
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Duty to Warn and Professional Responsibility
• All mental health, medical and rehabilitation professionals have a duty to protect the individual and others from harm
• Confidentiality and private medical information does not apply in “duty to warn” situations
• Response to protect must be immediate and complete
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Mental Health or Rehabilitation Problem?
• Suicide risk increases following a brain injury
• Impulsive behavior, cognitive and emotional problems are complicating agents to depression and suicidal thoughts and plans
• Mental health and rehabilitation professionals must manage ongoing risk
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Adding to Client Safety
• Communication among rehab team members is vital
• Understanding risk factors• Establishing a safety net, know signs and
signals• Frank discussion with significant other and
family of risk potential and signs• Rapid response to risk upon first
identification• Identifying “triggers” or precursors• Consider cognitive, behavioral and
neurological issues • Coordinate psychiatric treatment with
counseling and rehabilitation efforts
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A Team Approach: Build a Safety Net
• The client• Their family, friends and
others outside of rehab• Rehabilitation professionals• Medical and mental health
professionals• Support people in the
community• A plan to respond in an
emergency
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The Whys?
• Role of depression and isolation• Affect dysregulation• Thinking and planning problems• Impulse Control Issues• Seizure Disorders, pre- and post-
ictal changes• Drug and alcohol abuse and
addiction• Anger/rage problems• Pre-existing Personality Disorders• Other aggressive behaviors
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The Contributing Factors: The Role of Brain Injury in Suicide
• Loss of self-esteem and social role• Economic problems• Job Loss• Relationship problems, loss of
friends• Adjustment to disability• Social Isolation and withdrawal• Cognitive, behavioral and
executive functioning deficits
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Warning Signs of Suicide
• Depression over loss of self and functional changes
• Despair, feelings of worthlessness • Previous attempts, pre and post TBI• Prior ideation with/without plan• Psychiatric history or exacerbation of pre-
existing illness• Emergence of psychiatric symptoms post
TBI• Psychosocial stressors related to TBI• Impulsive behaviours, executive dysfunction• Thinking, planning, decision making
problems• Mood state problems related to TBI
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Emergence of Suicidal Events in Individuals with TBI
• Depression is common following brain injury
• Co-morbid psychiatric diagnosis: pre-existing condition may be exacerbated and underlying, previously undiagnosed problems may surface, elevating risk
• Suicide event may not follow the model of feelings/thoughts, plan and act
• Previous history cannot be discounted• Individuals with a Neurobehavioral
Syndrome and/or a seizure disorder may present an enhanced risk
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Psychotherapeutic Strategies
• Recognize mood and feeling state triggers
• Provide definitive, safe behavioral alternatives
• Extend and solidify “safety net” strategies through key people and a safety plan
• Address substance use/abuse issues• Increase awareness of
nonverbal/behavioral cues• Recognize role of impulsivity in
dyscontrol
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Brain Injury and Mental Health Issues in Suicide Attempts
• Inseparable and intertwined• Brain injury may accelerate psychiatric
disorders• Neurobehavioral issues may enhance
risk• May occur at any time following injury,
not confined to early recovery• Social role recovery is strongly related
to emerging and chronic mental health issues
• Individuals with a brain injury will not “fit” the psychiatric model
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Risk Prevention
• Understand risk factors• Respond proactively to first signs• Use external controls to assure
safety• Involve mental health
professionals in treatment and in rehabilitation planning
• Assure continuity between mental health and rehabilitation providers to incorporate brain injury issues in treatment
• Maintain awareness of changes, including those which are subtle
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Suicide: Protective Factors
Life satisfaction Spirituality Sense of
responsibility to family
Children in home Reality testing
ability
Positive social support
Positive coping skills
Positive problem-solving skills
Positive therapeutic relationship
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Neurologic Rehabilitation Institute of Ontario
and
Neurologic Rehabilitation Institute at
Brookhaven Hospital
Suicide Attempts Following Traumatic Brain Injury: From Risk Identification to Prevention
Rolf B. Gainer, Ph.D.