Psychological Trauma: Theory, Research, Practice, and Policy 2015, Vol. 7, No. 3, 277–285

© 2015 American Psychological Association 1942-9681/15/$12.00 http://dx.doi.org/10.1037/tra0000026

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DSM–5 Posttraumatic Stress Disorder Symptoms Associated With Suicide Behaviors in Veterans Margaret Legarreta

Jessica Graham

VA Salt Lake City Health Care System, Salt Lake City, Utah, and University of Utah School of Medicine

VA Salt Lake City Health Care System, Salt Lake City, Utah

Lindsey North

C. Elliott Bueler

VA Salt Lake City Health Care System, Salt Lake City, Utah, and University of Utah School of Medicine

University of Utah School of Medicine

Erin McGlade and Deborah Yurgelun-Todd VA Salt Lake City Health Care System, Salt Lake City, Utah, and University of Utah School of Medicine A connection between suicidality and posttraumatic stress disorder (PTSD) has been consistently demonstrated; however, the underlying relationship between suicidality and PTSD remains unclear. The aim of this study was to examine patterns of DSM–5 PTSD symptom endorsement that differentiated veteran participants with and without a history of suicide behaviors. We enrolled 95 veterans, 32 of whom reported no suicide ideation (SI) or suicide attempts (SA). The 63 remaining participants reported a history of SI, with 28 of the 63 also reporting a historical SA. Participants completed a standardized diagnostic interview (Structured Clinical Interview for DSM–IV–TR; First, Spitzer, Gibbon, & Williams, 2002), structured interview of suicidal behaviors (Columbia–Suicide Severity Rating Scale; Posner et al., 2011), and selected clinical measures. Veterans who reported SI and/or SA were more likely to meet criteria for PTSD on DSM–5 than were veterans who reported neither SI nor SA. Participants who reported SA were more likely to meet criteria for clusters C and D. Finally, at the symptom level, those who reported SI were more likely to report experiencing feelings of alienation. Those who reported a SA were more likely to report avoidance of thoughts and feelings, inability to recall an important aspect of their trauma, persistent negative beliefs, diminished interest, and feelings of alienation. These findings suggest that targeting specific symptoms of PTSD may aid in treatment of suicidal thoughts and behaviors associated with PTSD. Keywords: suicide, PTSD, DSM–5, trauma, veterans

Symptomatology of posttraumatic stress disorder (PTSD) has been a hallmark of the human psyche across history; nevertheless, the technical diagnostic definition was not in existence until 1980 when the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM–III) included it as a psychiatric diagnosis (American Psychiatric Association [APA], 1987). The diagnosis of

PTSD was updated for the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM–IV–TR; APA, 2000), which stated that an individual could meet criteria for PTSD if a trauma was experienced as well as concurrent intense feelings of fear, helplessness, or horror. Additionally, meeting diagnostic manifestation of symptoms from three primary symptom clusters

This article was published Online First February 23, 2015. Margaret Legarreta, Rocky Mountain Network Mental Illness Research Education and Clinical Centers (MIRECC, VISN 19), VA Salt Lake City Health Care System, and Department of Psychiatry, University of Utah School of Medicine; Jessica Graham, Rocky Mountain Network Mental Illness Research Education and Clinical Centers (MIRECC, VISN 19), VA Salt Lake City Health Care System; Lindsey North, Rocky Mountain Network Mental Illness Research Education and Clinical Centers (MIRECC, VISN 19), VA Salt Lake City Health Care System, and Department of Psychiatry, University of Utah School of Medicine; C. Elliott Bueler, Brain Institute, University of Utah School of Medicine; Erin McGlade and Deborah Yurgelun-Todd, Rocky Mountain Network Mental Illness Research Education and Clinical Centers (MIRECC, VISN 19), VA Salt Lake City Health Care

System, Department of Psychiatry, University of Utah School of Medicine, and Brain Institute, University of Utah School of Medicine. This research is supported by the Department of Veterans Affairs Office of Academic Affiliations Advanced Fellowship Program in Mental Illness Research and Treatment, the Medical Research Service of the Veterans Affairs Salt Lake City Health Care System, the Department of Veterans Affairs Rocky Mountain Network Mental Illness Research, Education, and Clinical Center, and Veterans Health Administration Merit Review Grant 5I01CX000253-02. The views in this article are those of the authors and do not necessarily represent the official policy or position of the Department of Veterans Affairs or the United States Government. Correspondence concerning this article should be addressed to Margaret Legarreta, 500 Foothill Drive, Mail Code 116M, Salt Lake City, UT 84148. E-mail: [email protected] 277

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(reexperiencing, avoidance, and hyperarousal) was required, and the experienced symptoms must result in distress and/or functional impairment. PTSD has been shown to be highly correlated with a variety of comorbid conditions, including both suicidal ideation (SI) and suicidal attempts (SA; Brenner, Betthauser, Homaifar, Villarreal, Harwood, Staves, & Huggins, 2011; Tarrier & Gregg, 2004). Individuals with PTSD are more likely to experience SI than members of the general population, with some research suggesting that rates of SI may be three times greater in individuals with PTSD (Bell & Nye, 2007; Tarrier & Gregg, 2004). For example, in a sample of patients with PTSD studied by Tarrier and Gregg (2004), 38.3% reported experiencing SI, 8.5% reported definite plans associated with suicide, and another 9.6% reported a SA, equating to over half of the sample with PTSD experiencing some degree of suicidal risk. Further, individuals with PTSD are at increased risk for suicidality across the spectrum of severity, including ideation, ideation with plan, ideation with plan and intent (Tarrier & Gregg, 2004), attempts (Davidson, Stein, Shalev, & Yehuda, 2004; Wilcox, Storr, & Breslau, 2009), and suicide completions (Gradus, Suvak, Wisco, Marx, & Resick, 2013). Recent large population-based studies investigating the relationship between PTSD and death by suicide revealed a strong association between PTSD and death by suicide when controlling for both demographic and psychiatric confounds (Gradus et al., 2013). Meeting diagnostic criteria for PTSD also appears to be an independent predictor of attempted suicide, whereas prior traumatic experience alone has not shown this association (Wilcox et al., 2009). Although experiencing trauma alone is not sufficient for the development of PTSD or increased suicidality, particular risk factors for the development of PTSD have been identified. Being a veteran or active military member has received notable attention in the current literature as being a risk factor for PTSD, as well as for suicidality (Calabrese et al., 2011; Jakupcak et al., 2009). For instance, veterans with PTSD experience higher rates of suicidality than veterans without PTSD (Calabrese et al., 2011; Jakupcak et al., 2009). A recent study found that National Guard soldiers with PTSD were 5.4 times more likely to report experiencing suicidal ideation than soldiers without a PTSD diagnosis (Calabrese et al., 2011). Similar findings were revealed in a 2011 study documenting that even veterans with subthreshold PTSD were more likely to experience SI than veterans without PTSD symptoms (Jakupcak et al., 2011). Among Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans, those who screened positive for PTSD were over 4 times more likely to endorse experiencing SI than their counterparts without PTSD (Jakupcak et al., 2009). Results from Kotler, Iancu, Efroni, and Amir (2001) suggest that veterans with PTSD have an increased risk for suicide compared not only to healthy controls but also to patients with anxiety disorders other than PTSD. Additionally, PTSD in the veteran population has been associated with SI even when controlling for factors such as age, depression, and substance abuse, suggesting there is something about PTSD that significantly affects the occurrence of suicidal behaviors (Jakupcak et al., 2009). Although it is clear that there is a relationship between PTSD and suicidality of various severity levels, more research is needed to understand the relationship between PTSD symptoms and suicidal behavior (Panagioti, Gooding, Taylor, & Tarrier, 2013; Pompili et al., 2013). One potential avenue for investigation is exam-

ination of the PTSD clusters and symptom profiles associated with suicidality. To date, few studies have investigated the impact of specific PTSD symptom endorsement or symptom clusters and the association with suicidal behaviors (i.e., active SI and SA). In community samples of individuals with PTSD, findings have revealed that individuals who report suicide behaviors are more likely to experience arousal symptoms, reexperiencing symptoms, and avoidance and numbing symptoms (Panagioti et al., 2013). Findings investigating the relationship between DSM–IV–TR PTSD symptoms and SI in Vietnam veterans with chronic PTSD revealed that reexperiencing symptoms significantly predicted a greater degree of SI, whereas symptoms in the clusters of avoidance and hyperarousal did not (Bell & Nye, 2007). Similarly, Panagioti et al. (2013) found reexperiencing symptoms to be associated with suicide behaviors in combat veterans. Other findings suggest that SI is directly related to numbing symptoms in the veteran population (Hellmuth, Stappenbeck, Hoerster, & Jakupcak, 2012). Thus far, the literature has been both limited and inconsistent concerning specific DSM–IV–TR PTSD symptom clusters and suicide behaviors. Therefore, the aim of the current study is to explore these relationships to provide optimal health care. Given the recent release of the DSM–5 and newly developed criteria for PTSD (APA, 2013), the current investigation sought to examine the relationship between DSM–5 PTSD symptom and cluster endorsement and SI and SA in a sample of veterans. Although there are many similarities between the DSM–IV–TR and DSM–5 PTSD diagnostic criteria, there are also noteworthy differences that could potentially mitigate the relationship between PTSD by the DSM–5 criteria and suicidality. For example, the definition of trauma has been broadened, and an individual is no longer required to experience feelings of fear, helplessness, or horror during the index trauma. Additionally, a symptom criteria cluster has been added (i.e., Cluster D: Negative Alterations in Cognitions and Mood associated with the traumatic event), which begins to addresses cognitive aspects of PTSD. Finally, criteria have been added, omitted, or shifted to be encompassed by other symptom clusters, resulting in a different diagnostic rubric than previously used. As such, questions emerge as to what the association may be between suicide behaviors and the DSM–5 definition of PTSD and its accompanying symptoms. In the current study, lifetime SI and SA will be examined in relation to DSM–5 PTSD criteria. On the basis of previous literature, we hypothesized that PTSD symptoms would be related to both SI as well as SA. Further, we expected that veterans who reported experiencing a Criterion A stressor in addition to SI and SA would be more likely to meet criteria for the reexperiencing (Cluster B) symptoms and the negative alterations in mood and affect (Cluster D) symptoms.

Method Data used in the current investigation were collected as part of a larger study examining veterans’ health, clinical and mood symptoms, suicidality, substance abuse, and traumatic brain injury (TBI) (Yurgelun-Todd et al., 2011). The Institutional Review Boards at the University of Utah and the George E. Wahlen Department of Veterans Affairs (VA) Medical Center approved this study. All participants provided written informed consent

DSM–5 PTSD SYMPTOMS ASSOCIATED WITH SUICIDE

before participation in this study. Participants were recruited from the George E. Wahlen VA Medical Center and the community via local advertisements and by word of mouth.

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Participants Ninety-five veteran participants who reported a Criterion A stressor were included in the analyses. Of the 95 included participants, 32 did not report a history of SI or SA. Of the remaining 63 participants, all reported a history of SI, and 28 also reported a history of SA. Analyses were conducted assessing veterans with or without SI and with or without SA separately. Inclusion criteria for participants were as follows: being a male or female veteran between the ages of 18 and 55 years old, and having at least one lifetime DSM–5 Criterion A traumatic event. Exclusion criteria for all participants included major sensorimotor handicaps (e.g., deafness, blindness, paralysis), full-scale IQ ⬍80, and/or psychosis. Demographic data for the participants in this study are presented in Table 1 based on presence or absence of reported SI and SA. Overall, the groups did not differ on any demographic variables; therefore, overall participant characteristics are reported. Participants were predominantly male (77.9%) and White (84.6%). The mean age of participants was 37.10 (SD ⫽ 9.14), with a range of 21 to 54 years old. Participants reported an average of 14.35 (SD ⫽ 1.88) years of education, with a range of 12 to 19. In terms of military experience, most participants were in the Army (48.1%) during their service time, and they served an average of 8.94 (SD ⫽ 6.50) years of service, with a wide range of 1 to 29 years of service reported. Although there were participants from various rank

279

levels in their military service, most participants reported their highest rank to be an E-4 (38.8%), and participants reported a range of zero to five deployments, with an average number of deployments being 1.11 (SD ⫽ 1.17). Participants were also assessed for the presence of mental health diagnoses. As expected, participants in the two groups differed on presence of a diagnosis of PTSD; however, none of the other queried mental health disorders were significantly different between the two groups. A significant number of participants reported having experienced a TBI (78.8%), as well as having a diagnosis of major depressive disorder at some point in their lifetime (51.5%), and a substance use disorder (46.6%).

Procedures As part of the original study, measures described below were administered in person with the veteran participants. To assess DSM–5 criteria for PTSD, a checklist was created to account for changes in the criteria from DSM–IV–TR. Each diagnostic criterion in the DSM–5 was matched to its corresponding item from the Structured Clinical Interview for DSM–IV–TR (SCID–I/P; First, Spitzer, Gibbon, & Williams, 2002). New criteria to the DSM–5 PTSD diagnosis were identified and data from sources including the Trauma Symptom Index (TSI; Briere, 1995), Hamilton Rating Scale for Depression (HAM-D; Hamilton, 1960), and Profile of Mood States (POMS; Pollock, Cho, Reker, & Volavka, 1979), as well as methodical query were used to complete the DSM–5 PTSD checklist.

Table 1 Demographic Data

Age, in years (SD) Sex (male) Education (in years) Ethnicity White African American Hispanic Asian American Biracial Years of service (SD) No. of deployments (SD) Branch Army Navy Air Force Marines Army Reserve Army National Guard Rank (mode) E4 Diagnoses TBI MDD Dysthymia PTSD (DSM–5) Any substance abuse or dependence

SI (N ⫽ 35)

SA (N ⫽ 28)

No SI/SA (N ⫽ 32)

p

36.86 (8.96) 80.0% 14.57 (2.00)

39.25 (9.35) 78.6% 13.64 (1.22)

36.78 (9.64) 81.3% 14.59 (2.09)

.51 .97 .08 .23

85.7% 2.9% 5.7% 2.9% 2.9% 10.43 (7.30) 1.39 (1.45)

82.1% 0% 7.1% 0% 10.7% 9.34 (6.57) .93 (1.00)

81.3% 6.3% 12.5% 0% 0% 7.70 (5.79) 1.19 (1.08)

57.1% 2.9% 22.9% 8.6% 5.7% 2.9%

50.0% 17.9% 7.1% 21.4% 3.6% 0%

40.6% 9.4% 18.8% 25.0% 3.1% 3.1%

34.3%

32.1%

45.2%

85.7% 65.7% 5.7% 68.6% 37.5%

85.2% 71.4% 10.7% 85.7% 50.0%

71.9% 40.6% 3.1% 53.1% 60.7%

.24 .35 .53

.29 .29 .08 .48 .005 .20

Note. TBI ⫽ traumatic brain injury; MDD ⫽ major depressive disorder; PTSD ⫽ posttraumatic stress disorder; DSM–5 ⫽ Diagnostic and Statistical Manual of Mental Disorders (5th ed.; American Psychiatric Association (2013).

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Measures The Structured Clinical Interview for DSM–IV–TR (SCID–I/P). The SCID–I/P is a clinician-administered, semistructured interview used to determine Axis I diagnoses (First et al., 2002). Clinical researchers were trained to administer the interview and determine diagnoses reliably across study personnel. The SCID–I/P was administered by either a board-certified psychiatrist or a doctoral-level clinical psychologist. Diagnoses were confirmed via a consensus meeting of the doctoral level investigators. There were multiple and systematic ways that the new Criterion D2 (Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world) were assessed. If Item 2 of the HAM–D, assessing Guilt, was endorsed as a 2, 3, or 4, the item was coded as yes, and if the endorsement was a 0 or 1, the item was coded as no. Item 6 of the TSI was also used for Criterion D2. If Item 6 of the TSI (“Feeling empty inside”) was endorsed as a 2 or 3, the item was coded as yes, and if it was endorsed as a 1 or 2, it was coded as no. Additionally, Criterion D2 was also assessed with the use of Item 23 on the POMS (“Feeling unworthy”). If the item was endorsed as a 2, 3, or 4, it was coded as yes, and if it was endorsed as a 1 or 2, it was coded as no. For the new Criterion D3 (Persistent distorted blame of self or others for causing the traumatic event or resulting consequences), there was no available

alternative in the data set to determine whether the individual was experiencing this symptom. Criterion E2 (Reckless or self-destructive behavior) was systematically queried. Veterans were asked to rate on a Likert scale (0 ⫽ rarely/never to 4 ⫽ almost always), how frequently they “seek out dangerous activities” and “take chances regardless of risk.” If either item was endorsed as a 3 or 4, the item was coded as yes, and if either item was endorsed as 1 or 2, it was coded as no. In the event that data from the any of the measures were not available, the data were coded as missing. See Table 2 for a complete list of data sources for new DSM–5 PTSD criteria. Three doctoral-level investigators reviewed the above information and reached consensus on symptom endorsement. Each symptom associated with a diagnosis of DSM–5 PTSD was entered with a code of 0 for no and 1 for yes. Further, each symptom cluster (B, C, D, and E) was coded 0 if the diagnostic criteria were not met and coded 1 if they were met. Additionally, the investigators reached consensus regarding other comorbid Axis I diagnoses. The Columbia–Suicide Severity Rating Scale (C-SSRS). The C-SSRS was designed to provide clinicians and researchers with distinctions between suicidal behaviors to include ideation and attempts. Different constructs assess severity of intention for suicide; intensity of ideation for suicide (frequency, duration, controllability, deterrents, and reasons for suicide); attempts, in-

Table 2 DSM–5 Posttraumatic Stress Disorder Criteria and Data Source DSM–5 criteria

Corresponding item

A1). Direct exposure. A2). Witnessing, in person. A3). Indirectly, by learning that a close relative or close friend was exposed to trauma. If the event involved actual or threatened death, it must have been violent or accidental. A4). Repeated or extreme indirect exposure to aversive details of the event(s), usually in the course of professional duties (e.g., first responders; collecting body parts; professionals repeatedly exposed to details of child abuse). This does not include indirect nonprofessional exposure through electronic media, television, movies, or pictures. B1). Recurrent, involuntary, and intrusive memories. B2). Traumatic nightmares. B3). Dissociative reactions (e.g., flashback) which may occur on a continuum from brief episodes to complete loss of consciousness. B4). Intense or prolonged distress after exposure to traumatic reminders. B5). Marked physiologic reactivity after exposure to trauma-related stimuli. C1). Trauma-related thoughts or feelings. C2). Trauma-related external reminders. D1). Inability to recall key features of the traumatic event. D2). Persistent (and often distorted) negative beliefs and expectations about oneself or the world.

SCID–IV A1 SCID–IV A1 Investigator consensus from description of trauma on SCID–IV Investigator consensus from description of trauma on SCID–IV

D3). Persistent distorted blame of self or others for causing the traumatic event or resulting consequences D4). Persistent negative trauma-related emotions D5). Markedly diminished interest in (pretraumatic) significant activities D6). Feeling alienated from others D7). Constricted affect: persistent inability to experience positive emotions E1). Irritable or aggressive behavior E2). Self-destructive or reckless behavior. E3). Hypervigilance E4). Exaggerated startle response E5). Problems in concentration E6). Sleep disturbance

SCID–IV B1 SCID–IV B2 SCID–IV B3 SCID–IV B4 SCID–IV B5 SCID–IV C1 SCID–IV C2 SCID–IV C3 Yes on HAM–D (Item 2) or TSI (Item 6) or POMS (Item 23) No alternative data available SCID–IV A2 SCID–IV C4 SCID–IV C5 SCID–IV C6 SCID–IV D2 Systematic inquiry of participants SCID–IV D4 SCID–IV D5 SCID–IV D3 SCID–IV D1

Note. DSM–5 ⫽ Diagnostic and Statistical Manual of Mental Disorders (5th ed.; American Psychiatric Association (2013); SCID–IV ⫽ Structured Clinical Interview for DSM–IV–TR; HAM–D ⫽ Hamilton Rating Scale for Depression; TSI ⫽ Trauma Symptom Index; POMS ⫽ Profile of Mood States.

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DSM–5 PTSD SYMPTOMS ASSOCIATED WITH SUICIDE

cluding actual attempts, aborted attempts, interrupted attempts, preparatory behaviors for an attempts; and nonsuicidal selfinjurious behaviors (Posner et al., 2011). A final construct assesses the lethality of attempts (Posner et al., 2011). The C-SSRS has been found to have acceptable internal consistency (intensity subscale), convergent, divergent, and predictive validity (Posner et al., 2011). The measure has also demonstrated sensitivity to change and sensitivity and specificity (Posner et al., 2011). “Suicide ideation” was coded by assigning a 1 for yes if any form of suicide ideation was acknowledged by the participant. A score of 0 for no was assigned if the participant denied all forms of suicide ideation in his or her interview with the doctoral level researcher. Further, “suicide attempt” was coded by assigning a score of 1 for yes if any form of suicide attempt (actual, interrupted, or aborted) was reported by the participant. Similarly, if the participant denied any form of suicide attempt he/she was assigned a score of 0 for no. All information regarding suicidality refers to historical or lifetime suicidality. Trauma Symptom Inventory (TSI). The TSI is a self-report measure designed to assess the sequelae of trauma. Participants rate symptoms (over the previous 6 months) on a four point scale that ranges from 0 (never) to 3 (often) (Briere, 1995). The scale assesses symptoms in 10 different domain areas, including anxious arousal, depression, anger or irritability, intrusive experiences, defensive avoidance, dissociation, sexual concerns, dysfunctional sexual behavior, impaired self-reference, and tension reduction behaviors (Briere, 1995). Also included in the measure are three validity scales (Briere, 1995). Norms are provided based on gender and age. Adequate reliability and validity have been found for both civilian and veteran populations (Briere, 1995). In a VA population, internal consistency averaged across the 10 clinician scales was acceptable (Cronbach’s ␣ ⫽ .83) (Briere, 1995). As well, adequate convergent validity was demonstrated in a VA population when the TSI was compared with measures assessing similar domains (Beck Anxiety Inventory, Beck Depression Inventory, and the Personal Assessment Inventory; Briere, 1995). The Hamilton Rating Scale for Depression (HAM-D). The HAM-D is a widely used clinician-rated scale that assesses severity of depression. Although some have criticized the measure, it still considered a gold standard of measurement (Iannuzzo, Jaeger, Goldberg, Kafantaris, & Sublette, 2006). Reliability and validity of the measure is determined to be acceptable (Iannuzzo et al., 2006). Profile of Mood States (POMS). The POMS is a widely used self-report measure that consists of 65 adjectives that are rated by subjects on a 5-point scale (Pollock, Cho, Reker, & Volavka, 1979). Six factors have been identified across the adjectives (Pollock et al., 1979).

Results A series of chi-square tests of independence were conducted to examine the relationship between presence of PTSD and each cluster (B, C, D, E) and each symptom associated with DSM–5 PTSD and SI and/or SA. Veterans who reported either SI, ␹2(1, N ⫽ 63) ⫽ 5.05, p ⫽ .03, or SA, ␹2(1, N ⫽ 28) ⫽ 6.47, p ⫽ .01, were more likely than those who did not report SI or SA to have a diagnosis of PTSD. Because of the high rate of TBI in this sample, a layered chi square was used to examine the effect of TBI on the association between PTSD and SI and SA. In the sample

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with TBI, the relationship approached significance: SI, ␹2(1, N⫽ 63) ⫽ 3.54, p ⫽ .06; SA, ␹2(1, N ⫽ 28) ⫽ 3.15, p ⫽ .08. Analysis of clusters revealed that Cluster D (Negative Alterations in Cognitions and Mood)—SA, ␹2(1, N ⫽ 63) ⫽ 7.63, p ⫽ .006; SA - ␹2(1, N ⫽ 28) ⫽ 4.48, p ⫽ .03—and Cluster E (Arousal and Reactivity)—SA, ␹2(1, N ⫽ 63) ⫽ 9.52, p ⫽ .002; SA - ␹2 (1, N ⫽ 28) ⫽ 3.97, p ⫽ .05)—were more likely to be present among veterans with SI and/or SA than in those without either SI or SA. It is interesting to note that when only the participants with TBI were assessed for presence of symptom clusters, we found that individuals with SI and TBI were more likely to meet criteria for Cluster D, ␹2(1, N ⫽ 53) ⫽ 7.82, p ⫽ .005, but those with TBI and SA were not more likely to endorse Cluster D, ␹2(1, N ⫽ 23) ⫽ 2.82, p ⫽ .09. Participants with TBI were more likely to endorse Cluster E: SI, ␹2(1, N ⫽ 53) ⫽ 10.24, p ⫽ .001; SA, ␹2(1, N ⫽ 23) ⫽ 3.90, p ⫽ .05. Cluster B (Reexperiencing) was significantly more endorsed by participants with a TBI who also endorsed SI, ␹2(1, N ⫽ 63) ⫽ 4.95, p ⫽ .03, but not by the overall participants group, ␹2(1, N ⫽ 63) ⫽ 2.52, p ⫽ .11. Cluster B was not more likely to be met among participants who reported a SA, regardless of TBI status: SA with TBI, ␹2(1, N ⫽ 23) ⫽ 2.37, p ⫽ .12; Total SA, ␹2(1, N ⫽ 28) ⫽ 1.55, p ⫽ .21. Finally, Cluster C was no more likely to be endorsed those who reported SI, regardless of TBI status: Total SI, ␹2(1, N ⫽ 63) ⫽ 2.33, p ⫽ .13. However, Cluster C was significantly more endorsed for participants who reported SA, ␹2(1, N ⫽ 28) ⫽ 5.36, p ⫽ .02, but was not more endorsed for participants who reported a SA and a TBI, ␹2(1, N ⫽ 23) ⫽ 3.69, p ⫽ .06. Next, we conducted a symptom-level analysis. For clarity sake, only symptoms that are significant for the total veteran SI and SA groups are reported here. Please see Table 3 for all significant findings. Among participants SI those who reported lifetime SI also more frequently reported “feeling alienated” compared with those who did not report SI, ␹2(1, N ⫽ 63) ⫽ 4.23, p ⫽ .04. Among SA participants, several symptoms of Cluster D were more likely to be endorsed than by those who did not report SA: Inability to Recall an Important Aspect of the Trauma, ␹2(1, N ⫽ 28) ⫽ 5.72, p ⫽ .02; Persistent Negative Beliefs About the Self or World, -␹2(1, N ⫽ 28) ⫽ 5.09, p ⫽ .02; Diminished Interest in Previously Enjoyed Activities, ␹2(1, N ⫽ 28) ⫽ 6.54, p ⫽ .01; and Feeling Alienated, ␹2(1, N ⫽ 28) ⫽ 5.87, p ⫽ .02. We also found that, although not hypothesized, SA participants were more likely to meet criteria for Cluster C (Avoidance), ␹2(1, N ⫽ 28) ⫽ 5.36, p ⫽ .02, as well as the symptoms Avoidance of Thoughts and Feelings, ␹2(1, N ⫽ 28) ⫽ 3.85, p ⫽ .05. Finally, SA participants were also more likely to endorse one of the newly established specifiers—Depersonalization, ␹2(1, N ⫽ 28) ⫽ 6.05, p ⫽ .01—than were participants who did not report a lifetime history of SA.

Discussion On the basis of previous literature investigating the relationship between PTSD and suicide behaviors, we expected that in a veteran population, DSM–5 criteria for PTSD would be related to suicide behaviors. More specifically, we expected that reexperiencing symptoms and alterations in cognition and mood would be more prevalent among those with SI and SA than those without. Although a diagnosis of PTSD was indeed more common among

LEGARRETA ET AL.

282 Table 3 Symptom Endorsement Data by Group

Suicide ideation TBI (N ⫽ 30)

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Note.

TBI (N ⫽ 23)

Total (N ⫽ 28)

␹ (Df⫽1)

p

␹ (Df⫽1)

p

␹ (Df⫽1)

p

␹ (Df⫽1)

p

3.54 4.94 8.27 10.27 .891 1.42 .898 3.04 2.16 4.73 7.82 7.22 6.10 1.90 8.11 7.48 3.54 14.73 10.24 4.79 .990 9.32 4.41 15.39 8.11 .060 3.69

.06 .03 .004 .001 .35 .23 .34 .08 .14 .03 .005 .007 .01 .17 .004 .006 .06 .000 .001 .03 .320 .002 .04 .000 .004 .807 .06

5.05 2.52 3.86 7.45 1.51 1.76 1.92 2.33 2.33 3.82 7.62 6.62 9.04 .243 8.50 7.91 4.23 15.35 9.52 2.01 1.58 8.50 5.64 13.46 6.02 .096 4.38

.03 .11 .05 .006 .22 .19 .17 .13 .13 .05 .006 .01 .003 .62 .004 .005 .04 .000 .002 .16 .21 .005 .02 .000 .014 .757 .04

3.15 2.37 3.96 5.70 .446 .016 .003 3.69 2.01 4.99 2.82 3.51 1.88 .91 4.26 3.79 3.15 6.82 3.90 1.11 .063 4.26 1.85 9.88 1.75 .34 3.15

.08 .12 .05 .02 .50 .90 .96 .06 .16 .03 .09 .06 .17 .34 .04 .06 .08 .009 .05 .29 .80 .04 .17 .002 .19 .56 .08

6.47 1.55 4.87 7.34 2.78 .420 .129 5.36 3.85 6.54 4.48 5.72 5.09 1.27 5.93 6.54 5.87 10.62 3.97 .698 .004 5.36 2.43 12.21 3.26 .914 6.05

.01 .21 .03 .007 .10 .52 .72 .02 .05 .01 .03 .02 .02 .26 .02 .01 .02 .001 .05 .40 .95 .02 .12 .000 .07 .34 .01

2

Meets DSM–5 criteria Meets Criterion B Intrusive memories Traumatic nightmares Dissociative reactions Prolonged distress Physiological reactivity Meets Criterion C Avoid thoughts or feelings Avoid external reminders Meets Criterion D Inability to recall Persistent negative beliefs Persistent distorted blame Negative trauma emotions Diminished interest Feeling alienated Constricted affect Meets Criterion E Irritable or aggressive behavior Self-destructive or reckless behavior Hypervigilance Exaggerated startle response Problems in concentration Sleep disturbance Derealization Depersonalization

Suicide attempts

Total (N ⫽ 35) 2

2

2

TBI ⫽ traumatic brain injury; DSM–5 ⫽ Diagnostic and Statistical Manual of Mental Disorders (5th ed.; American Psychiatric Association (2013).

veterans with SI as well as with SA, neither group was more likely to report reexperiencing symptoms (Cluster B). However, the negative alterations in cognition and mood (Cluster D) symptoms were more prevalent among veterans who reported SA. An association between DSM–IV–TR PTSD and suicide behaviors has previously been reported; however, this is one of the first studies to report these findings with the new DSM–5PTSD criteria. Moreover, Cluster C (Avoidance) was related to SA in this sample of veterans. Consistent with previous literature, avoidance symptoms have been associated with suicide behaviors in a community sample (Panagioti et al., 2013); nonetheless, these findings have not been previously reported in a veteran population. Avoidance, especially in DSM–5, is a hallmark of PTSD and must be present in some form for the diagnosis to be given. At the individual symptoms level, there initially appeared to be a variety of PTSD symptoms associated with both SI and SA in veterans; however, when controlling for the influence of TBI on the findings, only a few symptoms remained related. In veterans who reported SI, only feelings of alienation remained significant. In those who reported an SA, avoidance of thoughts and feelings, inability to recall an important aspect of the trauma, persistent negative beliefs about the self and the world, diminished interest, and feelings of alienation remained significant. Further, one of the new specifiers associated with PTSD in DSM–5, depersonalization, was also significantly more common in veterans who reported SA, than in veterans who did not report SA. Thus far, limited

research has examined how these independent symptoms of PTSD are related to SI and SA. This pilot study has demonstrated the association of PTSD symptoms as they relate to SI or SA. Although these findings are preliminary, with further studies in this direction, it may be possible to augment current PTSD treatments to address the symptoms that seem increasingly relevant with populations who experience SI and SA. Specifically, negative cognitions, diminished interest in previous activities, and feelings of alienation may provide target domains for potential intervention. Feelings of alienation may be of particular interest given the research on the interpersonal theory of suicide that suggests thwarted belonging is one of the factors associated with suicide behaviors (Van Orden et al., 2010). The addition of symptoms including persistent negative beliefs and expectations about one’s self and the world, and blame of self and others, to the DSM–5 PTSD criteria demonstrates a noteworthy shift in the conceptualization of PTSD. Although these particular symptoms are new to the DSM–5 PTSD construct, they are not new to clinician conceptualization of PTSD, nor to current treatment models of PTSD. For example, these cognitive symptoms have been targets of change in cognitive processing therapy for quite some time now (Resick, Nishith, Weaver, Astin, & Feuer, 2002). More recently, brief cognitive behavioral therapy has been used with military populations in an effort to reduce suicide behaviors, thereby allowing patients to more fully engage in longer term therapies to address associated conditions, such as PTSD and

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DSM–5 PTSD SYMPTOMS ASSOCIATED WITH SUICIDE

major depressive disorder (Bryan et al., 2012; Rudd, 2012). Further, there is existing evidence from the current investigation, as well as evidence reported by Pompili et al. (2013), suggesting that these negative cognitive appraisals are associated with suicidality, and can be treated appropriately using cognitively based therapies. Perhaps the greatest clinical utility in understanding how certain PTSD symptoms relate to suicidality is the ability to assess risk more accurately. At this time, PTSD is one of the most prevalent psychiatric disorders among OEF/OIF veterans seeking mental health services (Jakupcak et al., 2009). Identification of unique symptoms and clusters within PTSD that are associated with suicidality may not only improve risk assessment, treatment, and treatment planning but may also provide a focus on what can be considered the most urgent mental health issue, namely suicide, regardless of the PTSD diagnosis or other comorbid conditions. It has been reported that of the OEF/OIF veterans with a psychiatric disorder, 27% have three or more comorbid mental health conditions (Seal, Bertenthal, Miner, Sen, & Marmar, 2007). Veterans with two or more comorbid mental health conditions in addition to PTSD are 5.7 times more likely to experience suicidal ideation, emphasizing the importance of not only treating PTSD, but in also targeting suicidality as well (Jakupcak et al., 2009). Although considerable research supports the association between PTSD and suicidality, examination has also supported the relationship between TBI and suicidality. In a recent study, TBI was found to be a correlate of SI. The authors reported that, specifically, loss of consciousness and having experience multiple TBIs were associated with greater SI risk (Wisco et al., 2014). It is interesting to note that after the authors controlled covariates, such as psychiatric comorbidity, the associations remained for male veterans but not for female veterans (Wisco et al., 2014). Finally, in addressing better risk assessment, understanding suicidality as a construct unto its own may be helpful and driven by understanding which symptoms are more commonly associated with typical clinical presentations. In addition to PTSD, suicide behaviors have been shown to be associated with other psychiatric disorders, such as major depression and borderline personality disorder (Oquendo & Currier, 2009), as well as physical health concerns, including pain (Ilgen et al., 2013) and TBI (Brenner, Ignacio, & Blow, 2011; Simpson & Tate, 2005). Given the prevalence of suicide across a variety of conditions, some researchers have argued that suicide should have its own diagnostic category (Oquendo & Currier, 2009).

Strengths and Limitations The current study offers some of the first data investigating the relationship between DSM–5 PTSD symptom patterns and suicide behaviors in veterans. Our findings suggest a clinically relevant approach to understanding how the changes in PTSD criteria can influence the conceptualization of suicidality. More specifically, our study included a large sample of veterans, which is a population that has demonstrated particular vulnerability to developing PTSD symptoms and suicidality. An additional strength of this study is that complete psychosocial interviews and assessment batteries were conducted in person by doctoral-level clinicians to ensure the accuracy of diagnoses. A systematic and objective manner for assessing the new DSM–5 PTSD criteria was implemented, thus ensuring accurate and reliable data. Further, although

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these data are preliminary in nature, this is a broad sample that includes both male and female veterans with a variety of comorbid health conditions, enabling us to comment on suicide behaviors affecting different individuals in the population. Nonetheless, there are several important limitations of this study to consider. Data used in the current investigation were collected as part of a larger study; therefore, several symptoms for DSM–5 PTSD criteria were extracted from symptom scales (e.g., structured clinical interviews, self-report measures, and clinical rated scales). In addition, we were unable to identify substitution data for Criterion 2 in Cluster D (i.e., Persistent distorted blame of self or others for causing the traumatic event or for resulting consequences); therefore, this criterion was not evaluated in the current investigation.

Future Directions As DSM–5 becomes part of regular clinical use, questions regarding the utility of newly added criteria will begin to emerge. Specifically, methods systematically querying all of the DSM–5 PTSD criteria should be used, and eliciting details of the traumatic experience and symptom onset, as well as gaining an understanding of the individual’s cognitive and emotional response to the trauma, should be a focus of future research. Further, interviews about suicidality should be supplemented by questions aimed at understanding the role the traumatic event played, and continues to play, in suicidal thoughts and behaviors. These types of queries will not only help clarify diagnosis but will also offer a starting point for comprehensive risk assessment and increasingly targeted treatment planning. Additional future research should examine the impact of demographics, comorbid conditions (both mental and physical health), and difference in trauma type on suicide behaviors. By gaining a better understanding of the particular manifestation of symptoms associated with suicide behaviors while also accounting for other individualized variables, clinicians would likely be better able to not only diagnose patients but also provide more targeted risk assessment and treatment interventions based on the patient’s unique demographics, history, and current comorbid conditions. Further, it may be that trauma type helps elucidate the relationship more clearly between PTSD symptoms and suicide behaviors.

Conclusions The current study examined patterns of DSM–5 PTSD symptom endorsement in veterans with and without a history of SI and/or SA and found a strong association between PTSD and SI and SA. Our hypotheses stated that PTSD would be related to both SI and SA and that veterans who reported experiencing a Criterion A stressor who also reported SI and/or SA would be more likely to meet criteria for the reexperiencing and negative alterations in mood and affect symptoms. These hypotheses were partially supported in that PTSD was related to both SI and SA. Further, the Negative Alteration in Cognition and Mood Cluster was related to SA. Specific symptoms were more likely to be related to SA than to SI. Furthermore, although it was not hypothesized, we found that the Avoidance Cluster was related to SA. As the diagnostic construct of PTSD continues to be honed, it is of clinical relevance to not only understand how these symptoms manifest in individuals but also how these particular symptoms are related to suicide

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behaviors. Clinicians armed with an improved understanding of PTSD symptoms and their relationship to suicide behaviors will be better able to assess risk accurately in individuals with PTSD and to tailor their interventions to target specific symptoms or symptom clusters in an effort to reduce suicidal ideation, attempts, and mortality.

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DSM–5 PTSD SYMPTOMS ASSOCIATED WITH SUICIDE

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Received August 1, 2014 Revision received October 17, 2014 Accepted December 4, 2014 䡲

DSM-5 posttraumatic stress disorder symptoms associated with suicide behaviors in veterans.

A connection between suicidality and posttraumatic stress disorder (PTSD) has been consistently demonstrated; however, the underlying relationship bet...
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