Transcript Suicide and Traumatic Brain Injury
www.nrio.com
www.traumaticbraininjury.net
Suicide Attempts Following Traumatic Brain Injury
From Risk Identification to Prevention Rolf B. Gainer, Ph.D.
Neurologic Rehabilitation Institute of Ontario Neurologic Rehabilitation Institute at Brookhaven Hospital
www.nrio.com
www.traumaticbraininjury.net
• • • •
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 Learning Objectives
www.nrio.com
www.traumaticbraininjury.net
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
www.nrio.com
www.traumaticbraininjury.net
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
www.nrio.com
www.traumaticbraininjury.net
factors which set the stage for suicide
isolated from others
history of abuse
history of trauma
socio-cultural losses
domestic violence
www.nrio.com
www.traumaticbraininjury.net
Why Live?
• • • • •
Confluence of negative feelings and self-directed anger Thinking about “the end” Developing plans Selecting
method
Implementation phase
www.nrio.com
www.traumaticbraininjury.net
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”
www.nrio.com
www.traumaticbraininjury.net
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
www.nrio.com
www.traumaticbraininjury.net
a personal life in turmoil
lack of social support network
isolation
barriers to accessing care
stigma of asking for help
www.nrio.com
www.traumaticbraininjury.net
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
www.nrio.com
www.traumaticbraininjury.net
enhancing the risk
impulsive behaviors, limited self regulation
failed sense of belonging
perceived burden on others
loss of fear of death and pain
www.nrio.com
www.traumaticbraininjury.net
“The Process” of Suicide
www.nrio.com
www.traumaticbraininjury.net
Depression & Despair
www.nrio.com
www.traumaticbraininjury.net
Life Not Worth Living
www.nrio.com
www.traumaticbraininjury.net
Loss of Self
www.nrio.com
www.traumaticbraininjury.net
Disconnecting
www.nrio.com
www.traumaticbraininjury.net
Creating “The Plan”
www.nrio.com
www.traumaticbraininjury.net
The Act: Lethal Impulse
www.nrio.com
www.traumaticbraininjury.net
A Different Model for Suicide
• • •
Ready Fire Aim
• • •
Ready Aim Fire
• • • • Role of impulsive behaviors Executive Dysfunction Thinking, planning, decision making problems Role of Mood state instability
www.nrio.com
www.traumaticbraininjury.net
Suicide and Cognition
•
“Thinking about thinking”
• •
Unable to withstand impulse “Getting stuck”
www.nrio.com
www.traumaticbraininjury.net
• • • • • • • • • • 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
A Model for Understanding Suicide
www.nrio.com
www.traumaticbraininjury.net
• • • • • •
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
www.nrio.com
www.traumaticbraininjury.net
• • • • • • 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)
The Research
www.nrio.com
www.traumaticbraininjury.net
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
www.nrio.com
www.traumaticbraininjury.net
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
www.nrio.com
www.traumaticbraininjury.net
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)
www.nrio.com
www.traumaticbraininjury.net
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
www.nrio.com
www.traumaticbraininjury.net
Aggression and Suicide
• • • • •
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 (Mann, The Neurobiology of Suicide and Aggression, 2000)
www.nrio.com
www.traumaticbraininjury.net
• • • • • • • • • 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
Issues of Diagnosis and Suicide Potential
www.nrio.com
www.traumaticbraininjury.net
• • • • • • 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
Brain Injury and Suicide Risk: Issues
www.nrio.com
www.traumaticbraininjury.net
• 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
Brain Injury Accelerates Psychiatric Conditions
www.nrio.com
www.traumaticbraininjury.net
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
www.nrio.com
www.traumaticbraininjury.net
• • • • • • • •
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”
www.nrio.com
www.traumaticbraininjury.net
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
www.nrio.com
www.traumaticbraininjury.net
• • • • • •
Suicide Probability Scale (SPS)
John Cull and Wayne Gill, 1988 SPS uses a four axis system Hopelessness Suicide Ideation Negative self-evaluation Hostility
A Four Axis Approach to Evaluating Suicide Risk
www.nrio.com
www.traumaticbraininjury.net
• • • • • • • • • • 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
Hopeless Indicators
www.nrio.com
www.traumaticbraininjury.net
• • • • • • 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
Suicidal Ideation Indicators
www.nrio.com
www.traumaticbraininjury.net
• • • • • • • 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
Negative Self Evaluation Indicators
www.nrio.com
www.traumaticbraininjury.net
• • • • • • 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
Hostility Indicators
www.nrio.com
www.traumaticbraininjury.net
• • • • • 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
Practical Aspects of the SPS
www.nrio.com
www.traumaticbraininjury.net
• • • • • • 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
Suicide Probability Scale (SPS)
www.nrio.com
www.traumaticbraininjury.net
• • • • • 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”
Suicide Probability Scale (SPS)
www.nrio.com
www.traumaticbraininjury.net
• • • • • • 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
Applying the Suicide Probability Scale to TBI
www.nrio.com
www.traumaticbraininjury.net
• • • • • • • 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
The Past, Present, and the Future
www.nrio.com
www.traumaticbraininjury.net
• • • • • • • 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
Risk Assessment Process
www.nrio.com
www.traumaticbraininjury.net
• • • • • 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)
Risk Assessment
www.nrio.com
www.traumaticbraininjury.net
TBI and Suicide: Shared Risk Factors
Age
Gender
Substance Use
Psychiatric Disorder
Aggressive Behavior
www.nrio.com
www.traumaticbraininjury.net
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
www.nrio.com
www.traumaticbraininjury.net
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
www.nrio.com
www.traumaticbraininjury.net
• • • • • • • 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?
Risk Identification Leads to Prevention
www.nrio.com
www.traumaticbraininjury.net
• • • • • • • 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
Passive Suicide
www.nrio.com
www.traumaticbraininjury.net
• • • • • • 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
The Role of High Risk Behaviors in Suicide Ideation and Acts
www.nrio.com
www.traumaticbraininjury.net
• • • • • • 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
“Suicide by Cop”: Passive or Active?
• • • • • •
www.nrio.com
www.traumaticbraininjury.net
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
Prevention and Treatment Issues
www.nrio.com
www.traumaticbraininjury.net
• • • • • 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
Prevention and Treatment Issues
www.nrio.com
www.traumaticbraininjury.net
• • • 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
Duty to Warn and Professional Responsibility
www.nrio.com
www.traumaticbraininjury.net
• • • 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
Mental Health or Rehabilitation Problem?
www.nrio.com
www.traumaticbraininjury.net
• • • • • • • • 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
Adding to Client Safety
www.nrio.com
www.traumaticbraininjury.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
A Team Approach: Build a Safety Net
www.nrio.com
www.traumaticbraininjury.net
• • • • • • • • • 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
The Whys?
www.nrio.com
www.traumaticbraininjury.net
• • • • • • • 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
The Contributing Factors: The Role of Brain Injury in Suicide
• • • • • • • • • •
www.nrio.com
www.traumaticbraininjury.net
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
Warning Signs of Suicide
www.nrio.com
www.traumaticbraininjury.net
• • • • • 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
Emergence of Suicidal Events in Individuals with TBI
www.nrio.com
www.traumaticbraininjury.net
• • • • • • 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
Psychotherapeutic Strategies
www.nrio.com
www.traumaticbraininjury.net
• • • • • • 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
Brain Injury and Mental Health Issues in Suicide Attempts
www.nrio.com
www.traumaticbraininjury.net
• • • • • • 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
Risk Prevention
www.nrio.com
www.traumaticbraininjury.net
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
www.nrio.com
www.traumaticbraininjury.net
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.