ADVANCES IN CLINICAL SUICIDOLOGY I

Role of childhood trauma and hostile behaviour in predisposing to suicidal attempts M. Sarchiapone, V. Carli, G. Camardese, C. Cuomo, M. Rizzo INSTITUTE OF PSYCHIATRY UCSC- ROME, ITALY PREDISPOSING FACTORS POTENTIATING FACTORS • Psychiatric Disorder • Substance Abuse • Neurobiological risk factors • Familiarity • Aggressive / Impulsive Behavior • Childhood trauma INSTITUTE OF PSYCHIATRY UCSC- ROME, ITALY • Life stresses • Medical illness • Availability of lethal means • Grief Hostile/Impulsive behavior Substance abuse Childhood trauma Suicidal Behavior Psychiatric Disorder INSTITUTE OF PSYCHIATRY UCSC- ROME, ITALY Types of childhood trauma Physical abuse by adults or peers  Sexual abuse by adults or peers  Neglect  Psychological maltreatment  Witnessing violence, especially against the mother  Family members with substance use, mental disorders, suicidality  Loss or separation from parents  Childhood socioeconomic disadvantage  INSTITUTE OF PSYCHIATRY UCSC- ROME, ITALY Prevalence of childhood trauma  The overall child victimization rate is estimated about 12 per 1000 with only very small gender differences. Children are often exposed to more than one type of trauma: – 1/3 to 1/2 of neglected children witness domestic violence. – Child neglect frequently occurs in households with maternal depression. – 1/3 of abused adults report both physical and sexual abuse as children. Felitti et al. 1998; De Bellis 2001; Glaser 2000; McCauley et al. 1997  INSTITUTE OF PSYCHIATRY UCSC- ROME, ITALY Prevalence of different types of childhood trauma 10% 21% 58% 11% Neglect Sexual Abuse Physical Abuse Other INSTITUTE OF PSYCHIATRY UCSC- ROME, ITALY  Childhood trauma is underreported and under-estimated – Only the more severe and substantiated cases are reported to the authorities. – Other causes of under-reporting  Forgetting  Stigma and embarassment  Relationship to the perpetrator  Repression INSTITUTE OF PSYCHIATRY UCSC- ROME, ITALY Childhood Trauma as a Risk Factor for Psychopathology Psychiatric Disorder Odds Ratio Major Depression Anxiety Disorder Conduct Disorder 5.4 3.2 11.9 Alcohol Abuse/Dependence Other Substance Abuse/Dependance Suicide Attempt Ferguson et al. 1996 2.7 6.6 5.0 INSTITUTE OF PSYCHIATRY UCSC- ROME, ITALY Childhood Trauma as a Risk Factor for Suicidal Behavior  Childhood trauma and suicidal behavior in drug addicts* (N=449) and alcoholics** (N=280).  Patients who had attempted suicide had significantly higher scores for emotional abuse, physical abuse, sexual abuse, emotional neglect and physical neglect than patients who never attempted suicide •* A. Roy. Psych Res 121 (2003):99-103 •**A. Roy. J Aff Dis 77 (2003):267-271 INSTITUTE OF PSYCHIATRY UCSC- ROME, ITALY Childhood Trauma Psychological and behavioral effects Low self-esteem Poor attachment Substance Use Suicidal Behavior INSTITUTE OF PSYCHIATRY UCSC- ROME, ITALY Childhood Trauma Neurobiological effects on the developing Brain Stress Response Systems Neurotransmitters Suicidal Behavior INSTITUTE OF PSYCHIATRY UCSC- ROME, ITALY Neurobiological effects of childhood trauma In a sample (N=29) of abstinent cocaine dependent patients, childhood emotional neglect scores showed significant negative correlations with CSF concentrations of 5-HIAA and HVA. A. Roy. Psych Res 112 (2002):69-75 Cocaine dependent adults with low Urinary free cortisol output, showed higher CTQ scores for childhood sexual abuse. A. Roy. J Psych Res 36 (2002): 173-177 INSTITUTE OF PSYCHIATRY UCSC- ROME, ITALY Predisposing factors Suicide Suicidal threshold Potentiating Factors ---------- Survival Protective factors INSTITUTE OF PSYCHIATRY UCSC- ROME, ITALY Resiliency  Resiliency is the ability to spring back from and successfully adapt to adversity.  Bouncing back from problems with more power and more smarts INSTITUTE OF PSYCHIATRY UCSC- ROME, ITALY Study on biological and psychopathological markers of suicidal behavior Patients recruited at the Day Hospital of Clinical Psychiatry of the Catholic University of Sacred Heart in Rome, Italy. Bipolar Eating Dis. Alcoholics Schizophrenia Recruitment Emergency Other wards Drug addicts Depression Psychometric testing Blood sample Biology and genetics INSTITUTE OF PSYCHIATRY UCSC- ROME, ITALY Objectives  Examine a series of psychopathological factors in a population of suicide attempters with depressive disorder.  Search correlations between childhood trauma, severity of depressive illness, hostility and suicidality. INSTITUTE OF PSYCHIATRY UCSC- ROME, ITALY Study subjects  143 patients with Unipolar Depression (Mean age: 45.14±11.27; Males/females: 51/92)    N=49 Major Depression, Single Episode N=94 Major Depression, Recurrent N=4 Dysthymia   27 patients (18.8%) had a comorbid anxiety disorder. 11 patients (7.7%) had a comorbid substance abuse disorder. • 58 patients (40.5%) had a lifetime suicide attempt in psychiatric history. INSTITUTE OF PSYCHIATRY UCSC- ROME, ITALY Study subjects  Inclusion criteria: – DSM-IV diagnosis of unipolar depressive disorder – HDRS score ≥ 18 – Informed consent  Exclusion criteria: – Lifetime history of bipolar disorder, schizophrenia or other psychosis. – Mental retardation INSTITUTE OF PSYCHIATRY UCSC- ROME, ITALY Method   MINI Interview Semistructured interview     Patient’s history with special attention for number, method, intention and lethality of suicide attempts Sociodemographic variables Current treatment with psychoactive drugs Current treatment for a medical disorder      Brown Goodwin Interview (BGI) Hamilton Depression Rating Scale (HDRS) Eysenck Personality Questionnaire (EPQ) Childhood Trauma Questionnaire (CTQ) Connor Davidson Resilience Scale (CD-RISC) INSTITUTE OF PSYCHIATRY UCSC- ROME, ITALY Childhood Trauma Questionnaire items version  Self administered  Yields scores for:  Emotional  34 abuse  Physical abuse  Sexual abuse  Emotional neglect  Physical neglect INSTITUTE OF PSYCHIATRY UCSC- ROME, ITALY Results Total N=143 Attempters N=58 Non-Attempters N=85 Age (NS) Females* Single* Unemployed* HDRS EPQ P EPQ E EPQ N 45.14±11.27 64.3% 57.2% 23.4% 23.15±5.37 5.54±3.52 8.73±3.95 16.66±4.10 40.96±14.37 69.1% 65.4% 33.7% 23.47±5.19 5.82±3.67 8.76±3.89 16.29±4.03 47.27±13.25 58.2% 53.2% 18.3% 22.54±4.86 5.27±3.41 8.69±4.06 17.01±4.20 CD-RISC*# BGI* 55.63±9.36 31.48±6.69 49.11±5.46 34.86±5.11 62.37±3.37 24.95±9.48 *Statistically significant difference between Att. and Non-att. #Administered to 37 patients INSTITUTE OF PSYCHIATRY UCSC- ROME, ITALY 70 60 50 40 30 20 10 0 Age * * * * * SA NA Female Single Empl. HDRS EPQ P EPQ E EPQ N BGI CDRISC *=p<0.01 INSTITUTE OF PSYCHIATRY UCSC- ROME, ITALY Results (CTQ) Total N=143 Emotional abuse* Physical abuse Sexual abuse Emotional neglect* Physical neglect 9.97±5.14 7.86±4.42 7.66±4.14 26.94±10.11 11.06±3.99 Attempters N=58 11.68±5.46 8.38±4.44 8.19±4.92 30.13±9.64 11.17±4.39 Non-Attempters N=85 7.46±3.37 7.09±4.36 6.87±2.48 22.25±9.01 10.91±3.38 Total Score* 9.04±3.09 10.02±3.03 7.62±2.62 *Statistically significant difference between Att. And Non-att. INSTITUTE OF PSYCHIATRY UCSC- ROME, ITALY 30 25 20 15 10 5 0 EA *=p<0.01 * * * SA NA PA SA EN PN TWS INSTITUTE OF PSYCHIATRY UCSC- ROME, ITALY Results Statistically significant correlations were found between BGI total scores, Emotional abuse (r=0.49; p<0.01) and physical neglect (r=0.37; p<0.05) in patients who attempted suicide. 25,0 25,0 20,0 EA 15,0 PhysicNeg PsychAb PN 20,0 15,0 10,0 10,0 5,0 BGI 20,0 25,0 30,0 35,0 40,0 45,0 50,0 P<0.01 BGI BGHI P<0.05 20,0 25,0 30,0 35,0 40,0 45,0 50,0 BGHI These correlations were not found in the group of patients who didn’t attempt suicide INSTITUTE OF PSYCHIATRY UCSC- ROME, ITALY Resiliency and Childhood trauma 60 50 Emotional Neglect 40 30 20 10 0 0 10 20 30 40 CD-RISC 50 60 70 80 90 100 Resiliency scores were negatively correlated (p<0.05) with Emotional Neglect. INSTITUTE OF PSYCHIATRY UCSC- ROME, ITALY Conclusion •All the study participants were affected by a depressive disorder and CTQ scores appeared to be linked to the lifetime presence of a suicide attempt independently from the diagnosis of major depression. •There was no significant association between HDRS total scores and suicide attempts nor between HDRS scores and CTQ scores. •Suicide attempters had significantly higher CTQ subscores for Emotional Abuse and for Emotional Neglect. •These results suggest that childhood trauma may be a risk factor for suicidal behavior independently from severity of depression. It may be a predisposing factor that acts directly on aggressive/self-harm attitudes, regardless of a specific mental illness. INSTITUTE OF PSYCHIATRY UCSC- ROME, ITALY  Implications treatment for prevention and – If childhood trauma is an independent predictor then victims should be targeted for prevention programs, regardless of whether they already developed psychopathology. INSTITUTE OF PSYCHIATRY UCSC- ROME, ITALY  Hostility scores were significantly higher in the suicide attempters group. BGI scores were significantly correlated with emotional abuse, sexual abuse and physical neglect.   Our findings are in agreement with previous evidence (A. Roy, 2001) and support the hypothesis that hostility may be a “mediator” between childhood trauma and suicidal behavior. INSTITUTE OF PSYCHIATRY UCSC- ROME, ITALY Parent Genes for aggressive/impulsive behavior Aggressive Behavior Inheritance Childhood Trauma Son High risk for suicide Hostile behavior INSTITUTE OF PSYCHIATRY UCSC- ROME, ITALY Resiliency, childhood trauma and suicidal behavior  Suicide attempters showed mean lower scores on the Connor and Davidson Scale scores were negatively related to “Emotional neglect” scores  Resiliency INSTITUTE OF PSYCHIATRY UCSC- ROME, ITALY Childhood Trauma Hostile Behavior Low Resiliency Psychopathology High Suicidal Risk INSTITUTE OF PSYCHIATRY UCSC- ROME, ITALY  Further studies are needed on larger populations of depressed patients in order to confirm our findings. A larger sample would permit to analyze if specific depressive symptoms are less severe in patients with childhood trauma and violent behavior. Longitudinal studies are also needed to better investigate the pathways that from childhood trauma lead to suicidality and to reveal protective factors and processes and effective means of prevention and intervention across the lifespan. Tools for recognizing and treating childhood abuse victims may be capable to reduce suicide.   INSTITUTE OF PSYCHIATRY UCSC- ROME, ITALY