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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. Learning Objectives.

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suicide attempts following traumatic brain injury

Suicide Attempts Following Traumatic Brain Injury

From Risk Identification to Prevention

Rolf B. Gainer, Ph.D.

Neurologic Rehabilitation Institute of OntarioNeurologic Rehabilitation Institute atBrookhaven Hospital

learning objectives
Learning Objectives
  • Identify psychiatric and psychological issues associated with suicidal behavior following TBI
  • Identify risk factors related to suicide
  • Develop an understanding of a multi-axial approach to assessment
  • Identify methods to reduce risk and address suicidality
by the numbers
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
the geography of suicide risk
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
factors which set the stage for suicide
factors which set the stage for suicide
  • isolated from others
  • history of abuse
  • history of trauma
  • socio-cultural losses
  • domestic violence
why live
Confluence of negative feelings and self-directed anger

Thinking about “the end”

Developing plans

Selecting method

Implementation phase

Why Live?
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”

The TBI Factors
bringing a tbi home
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
a personal life in turmoil
a personal life in turmoil
  • lack of social support network
  • isolation
  • barriers to accessing care
  • stigma of asking for help
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

Setting the Stage
enhancing the risk
enhancing the risk
  • impulsive behaviors, limited self regulation
  • failed sense of belonging
  • perceived burden on others
  • loss of fear of death and pain
a different model for suicide



A Different Model for Suicide
  • Ready
  • Fire
  • Aim
  • Role of impulsive behaviors
  • Executive Dysfunction
  • Thinking, planning, decision making problems
  • Role of Mood state instability
suicide and cognition
“Thinking about thinking”

Unable to withstand impulse

“Getting stuck”

Suicide and Cognition
a model for understanding suicide
A Model for Understanding Suicide
  • Self worth vs. worthlessness
  • Hopelessness/depression/despair
  • Anger/Hostility
  • Plan
  • Method
  • Access
  • Previous history of suicidal thoughts and attempts
  • Capacity to act on plan
  • Social withdrawal
  • In TBI cases, impulsivity is an important factor
prevalence risk
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
the research
The Research
  • Social Withdrawal Syndrome (Sugarman, 1999)
  • Role of Affective Disorders (Morton and Wehman, 1995)
  • Awareness of deficits (Prigatano, 1996)
  • Disinhibition Syndrome (Shulman, 1997)
  • TBI as a stressful life event (Frey, 1995)
  • Increased risk associated with Mild TBI, psychiatric diagnosis and psychosocial disadvantage (Teasdale and Engberg, 2000)
the perfect storm tbi and suicide
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
a better storm tbi ptsd
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
second suicide attempt greater risk
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)
understanding the second attempt
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
aggression and suicide

Trigger/Life Event

Perception of Attack/Injury/Threat



External Aggressive Act

Suicidal Act

Depression following TBI

Perception of Depression and Suicidal Ideation

Suicidal Planning


Suicidal Act

Aggression and Suicide

(Mann, The Neurobiology of Suicide and Aggression, 2000)

issues of diagnosis and suicide potential
Issues of Diagnosis and Suicide Potential
  • Depression
  • Bipolar Disease/Manic Depression
  • Psychosis/Thinking disorder
  • Personality Disorders/Borderline Personality
  • Seizure Disorders/Pre and Post-Ictal Changes
  • Impulse Control Problems
  • Drug/alcohol abuse and addiction
  • Anger/Rage problems/ Episodic Explosive Disorder
  • Relationship of suicidal act to other aggressive acts
brain injury and suicide risk issues
Brain Injury and Suicide Risk: Issues
  • History of prior attempts, pre- and post injury
  • History of psychiatric illness, pre and post injury
  • History of suicide in other family members
  • Passive ideation without an active plan
  • Role of disinhibition, including medication related problems
  • Anger/emotional dysregulation
brain injury accelerates psychiatric conditions
Brain Injury Accelerates Psychiatric Conditions
  • Thinking problems
  • Emotional response to injury and disability
  • Difficulties with impulse control and self-regulation
  • Role of memory problems
  • Compliance with treatment
  • Social withdrawal
  • Social role changes
  • Perceived failure
mood state and behavioral changes
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
impulse control issues
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”
trigger events
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
a four axis approach to evaluating suicide risk
A Four Axis Approach to Evaluating Suicide Risk
  • Suicide Probability Scale (SPS) John Cull and Wayne Gill, 1988
  • SPS uses a four axis system
  • Hopelessness
  • Suicide Ideation
  • Negative self-evaluation
  • Hostility
hopeless indicators
Hopeless Indicators
  • Loneliness
  • Inability to change life
  • Problems doing things, initiation
  • Not important to others
  • Unable to meet expectations
  • Few friends
  • No future/no improvement
  • Perceived disapproval by others
  • Feeling tired/listless
  • Can’t find happiness
suicidal ideation indicators
Suicidal Ideation Indicators
  • Punish others by suicide
  • Punish self
  • “Better off dead”
  • “Less painful to die then living this way”
  • Thought of a plan/method
  • Think of suicide
negative self evaluation indicators
Negative Self Evaluation Indicators
  • Not feeling like a worthwhile person
  • Not feeling appreciated by others
  • Not missed by others if dead
  • Things don’t go well
  • Not close to mother
  • Not close to father
  • Not close to significant other
hostility indicators
Hostility Indicators
  • Anger/rage control, “gets mad easily”
  • Impulsive acts
  • Angry feelings towards others
  • Feels isolated from others
  • Senses anger from others
  • Can’t find a job/activity that I like
practical aspects of the sps
Practical Aspects of the SPS
  • Establishes scores in four domains
  • Compares score to “average” and standard deviation
  • Combines raw score data into a weighted T-score to define “probability”
  • Ranks probability risk from mild to severe
  • Considers major stressors/upsets over last two years, including past attempts in assessing risk potential
suicide probability scale sps
Suicide Probability Scale (SPS)
  • Predicts risk potential based on self-report of the individual to questions
  • The four axis model provides relationship to dimensions of suicide
  • Clinical importance/relevance of questions relates to risk factors
  • Limited bias caused by age, gender or ethnicity
  • Can be re-administered without practice learning bias
  • Current mood state dependent
suicide probability scale sps42
Suicide Probability Scale (SPS)
  • Axial approach provides an opportunity to assess potential for suicidal thinking, planning and acting
  • Risk potential is assigned using data from the four domains of the scale
  • Test questions relate to current emotional state
  • Instrument supports, but does not replace a clinical interview and assessment
  • Specific questions/response trigger “risk”
applying the suicide probability scale to tbi
Applying the Suicide Probability Scale to TBI
  • Cognitive issues must be considered
  • Reading and comprehension support may be required
  • The role of denial may effect score and obscure certain risk factors
  • Impulsive behaviour(s) will accelerate risk potential
  • Planning of suicide, including access and method may be poorly organized, but risk potential may be high
  • Passive issues may be significant to risk
the past present and the future
History of prior attempts, pre- and post-injury

History of psychiatric illness, pre- and post-injury

Suicide in other family members

Passive ideation without plan

Role of disinhibition

Substance abuse, prescription drug reaction

Anger/emotional dysregulation

The Past, Present, and the Future
risk assessment process
Risk Assessment Process
  • Clinical assessment based on presentation of suicidal thoughts and plan and the individual’s current mental state
  • Assessment must include current psychological/psychiatric issues and diseases, past history and psychological stressors
  • Use of an assessment instrument will highlight issues, but cannot be used solely without a further assessment
  • Current behavioral risk issues must be evaluated
  • Prevalence of impulsive behaviors in individuals with TBI will enhance risk potential
  • Lack of planning due to cognitive deficits does not exclude the individual from risk assignment
  • Mood state issues must be considered
risk assessment
Risk Assessment
  • Current stressors and/or life changes
  • Medication and its effects
  • Substance use/abuse
  • Specific problem(s) that the individual cannot solve
  • Engagement in other self-harmful behavior(s)
tbi and suicide shared risk factors
TBI and Suicide: Shared Risk Factors
  • Age
  • Gender
  • Substance Use
  • Psychiatric Disorder
  • Aggressive Behavior
a clear and present danger
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
watch for the warning signs
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
risk identification leads to prevention
Risk Identification Leads to Prevention
  • Is there evidence of suicidal thinking or self-harm?
  • Has the person experienced a loss of self-worth related to their disability?
  • Is there evidence of depression, including vegetative symptoms?
  • Is there a plan and/or method for the act?
  • Is there a passive component?
  • Is there a past history of suicide attempts?
  • Has anger or hostility increased in response to internal or external events?
passive suicide
Passive Suicide
  • Feeling they would be “better off dead”
  • “I wish I died in the accident”
  • “I wish God would take me away”
  • Feelings of loneliness and isolation
  • Need to punish self
  • Desire to punish others through suicide
  • Exposure to risk or engagement in risky behavior and activities
the role of high risk behaviors in suicide ideation and acts
The Role of High Risk Behaviors in Suicide Ideation and Acts
  • Engagement in high risk behaviors can be the plan for suicide
  • Plan may include motor vehicles, sport activities, fights, drug/alcohol use
  • Individual may not see themselves as the “active participant” and may express that these activities provide “relief”
  • History may include multiple accidents, overdoses, fights
  • Impaired judgment may initiate plan and act
  • Stress event may trigger attempt
suicide by cop passive or active
“Suicide by Cop”: Passive or Active?
  • Setting up event to occur
  • Using law enforcement or military action to stage event
  • Requires planning and capacity to operate plan
  • Individual is resigned to completing the event, no “fail safe” mechanism
  • Unlikely to communicate plan to others
  • High likelihood of other risk factors being present
prevention and treatment issues
Prevention and Treatment Issues
  • Use clinical interview and assessment to determine risk
  • Refer to mental health professionals for emergency evaluation and care
  • Refer to law enforcement to prevent person from moving forward with plan
  • Avoid “contracting for safety” in situations where the person is outside of appropriate and immediate supervision
  • Person may express relief or calm when a plan is established
  • Maintain awareness of non-verbal behaviors and cues
prevention and treatment issues55
Prevention and Treatment Issues
  • Maintain contact with the person, establish their location
  • Keep them engaged/talking
  • Enlist help from another person to contact mental health or law enforcement
  • Avoid argument or confrontation
  • Avoid value judgments
duty to warn and professional responsibility
Duty to Warn and Professional Responsibility
  • All mental health, medical and rehabilitation professionals have a duty to protect the individual and others from harm
  • Confidentiality and private medical information does not apply in “duty to warn” situations
  • Response to protect must be immediate and complete
mental health or rehabilitation problem
Mental Health or Rehabilitation Problem?
  • Suicide risk increases following a brain injury
  • Impulsive behavior, cognitive and emotional problems are complicating agents to depression and suicidal thoughts and plans
  • Mental health and rehabilitation professionals must manage ongoing risk
adding to client safety
Adding to Client Safety
  • Communication among rehab team members is vital
  • Understanding risk factors
  • Establishing a safety net, know signs and signals
  • Frank discussion with significant other and family of risk potential and signs
  • Rapid response to risk upon first identification
  • Identifying “triggers” or precursors
  • Consider cognitive, behavioral and neurological issues
  • Coordinate psychiatric treatment with counseling and rehabilitation efforts
a team approach build a safety net
A Team Approach: Build a Safety Net
  • The client
  • Their family, friends and others outside of rehab
  • Rehabilitation professionals
  • Medical and mental health professionals
  • Support people in the community
  • A plan to respond in an emergency
the whys
Role of depression and isolation

Affect dysregulation

Thinking and planning problems

Impulse Control Issues

Seizure Disorders, pre- and post-ictal changes

Drug and alcohol abuse and addiction

Anger/rage problems

Pre-existing Personality Disorders

Other aggressive behaviors

The Whys?
the contributing factors the role of brain injury in suicide
The Contributing Factors: The Role of Brain Injury in Suicide
  • Loss of self-esteem and social role
  • Economic problems
  • Job Loss
  • Relationship problems, loss of friends
  • Adjustment to disability
  • Social Isolation and withdrawal
  • Cognitive, behavioral and executive functioning deficits
warning signs of suicide
Warning Signs of Suicide
  • Depression over loss of self and functional changes
  • Despair, feelings of worthlessness
  • Previous attempts, pre and post TBI
  • Prior ideation with/without plan
  • Psychiatric history or exacerbation of pre-existing illness
  • Emergence of psychiatric symptoms post TBI
  • Psychosocial stressors related to TBI
  • Impulsive behaviours, executive dysfunction
  • Thinking, planning, decision making problems
  • Mood state problems related to TBI
emergence of suicidal events in individuals with tbi
Emergence of Suicidal Events in Individuals with TBI
  • Depression is common following brain injury
  • Co-morbid psychiatric diagnosis: pre-existing condition may be exacerbated and underlying, previously undiagnosed problems may surface, elevating risk
  • Suicide event may not follow the model of feelings/thoughts, plan and act
  • Previous history cannot be discounted
  • Individuals with a Neurobehavioral Syndrome and/or a seizure disorder may present an enhanced risk
psychotherapeutic strategies
Psychotherapeutic Strategies
  • Recognize mood and feeling state triggers
  • Provide definitive, safe behavioral alternatives
  • Extend and solidify “safety net” strategies through key people and a safety plan
  • Address substance use/abuse issues
  • Increase awareness of nonverbal/behavioral cues
  • Recognize role of impulsivity in dyscontrol

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

risk prevention
Risk Prevention
  • Understand risk factors
  • Respond proactively to first signs
  • Use external controls to assure safety
  • Involve mental health professionals in treatment and in rehabilitation planning
  • Assure continuity between mental health and rehabilitation providers to incorporate brain injury issues in treatment
  • Maintain awareness of changes, including those which are subtle
suicide protective factors
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

Neurologic Rehabilitation Institute of Ontario andNeurologic Rehabilitation Institute at Brookhaven Hospital

Suicide Attempts Following Traumatic Brain Injury: From Risk Identification to Prevention

Rolf B. Gainer, Ph.D.