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 postictal 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 preexisting 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: preexisting 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.