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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
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• 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
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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 others
 history of abuse
 history of trauma
 socio-cultural losses
 domestic violence
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Why Live?
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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
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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
 isolation
 barriers to accessing care
 stigma of asking for help
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Setting the Stage
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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 belonging
 perceived burden on others
 loss 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
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Ready
Fire
Aim
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Ready
Aim
Fire
Role of impulsive behaviors
Executive Dysfunction
Thinking, planning, decision
making problems
Role of Mood state instability
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Suicide and Cognition
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“Thinking about
thinking”
Unable to withstand
impulse
“Getting stuck”
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• 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
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Prevalence & Risk
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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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•
Social Withdrawal Syndrome (Sugarman,
1999)
•
Role of Affective Disorders (Morton and
Wehman, 1995)
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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
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The Perfect Storm: TBI
and Suicide
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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
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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
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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 and Suicide
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Aggression
Trigger/Life Event
Perception of
Attack/Injury/
Threat
Anger
Impulsivity
External
Aggressive Act
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Suicidal Act
Depression
following TBI
Perception of
Depression and
Suicidal Ideation
Suicidal Planning
Impulsivity
Suicidal Act
(Mann, The Neurobiology of Suicide and Aggression, 2000)
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• Depression
• Bipolar Disease/Manic Depression
• Psychosis/Thinking disorder
• Personality Disorders/Borderline
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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
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• History of prior attempts, pre-
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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
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• 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
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Mood State and Behavioral Changes
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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
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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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• Suicide Probability Scale
(SPS) John Cull and Wayne
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Gill, 1988
SPS uses a four axis system
Hopelessness
Suicide Ideation
Negative self-evaluation
Hostility
A Four Axis Approach to Evaluating Suicide Risk
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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
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• 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
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• Not feeling like a worthwhile
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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
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• Anger/rage control, “gets mad
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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
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• 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
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• Predicts risk potential based on
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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)
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• Axial approach provides an
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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)
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• Cognitive issues must be considered
• Reading and comprehension support
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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
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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
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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
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• Current stressors and/or life
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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
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TBI and Suicide:
Shared Risk Factors
 Age
 Gender
 Substance
Use
 Psychiatric Disorder
 Aggressive 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
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Feeling hopeless
Trapped, no
alternatives
Increased
drug/alcohol use
Dramatic mood
change
Withdrawal
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Anxiety, agitation
Sleep problems,
too little or too
much
Rage, anger,
revenge
Reckless actions
Lost purpose for
living
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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
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• Feeling they would be “better off
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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
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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
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• Setting up event to occur
• Using law enforcement or military
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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?
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• Use clinical interview and
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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
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• Maintain contact with the
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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
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• 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
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• 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?
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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
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• The client
• Their family, friends and
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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
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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?
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• 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
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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
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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
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• Recognize mood and feeling state
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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
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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
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• 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
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Suicide: Protective Factors
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Life satisfaction
Spirituality
Sense of
responsibility to
family
Children in
home
Reality testing
ability
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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.