Psychiatric Times.
No. 7
Childhood Adversities Associated With Risk for Suicidal Behavior
By Jochen Hardt, PhD, Jeffrey G. Johnson, PhD, Elizabeth A. Courtney, and Jitender Sareen, MD |
June 1, 2006
Theoretical models of suicide etiology
A number of different theoretical
models have been developed to explain
the underlying mechanisms that lead to
suicidal behavior.21,22,26,37,38 Several of these theories have included a wide
range of risk factors. In particular, some
recent models have focused on the association
between childhood adversities
and suicide risk. For example, Bergen
and associates43 constructed a model with 2 hypothesized paths from childhood
sexual abuse to suicide risk: (1)
via depression and (2) via hopelessness.
Suicide risk was defined as increased
suicide ideation, plans, threats, and
deliberate self-harm. Childhood sexual
abuse was associated with suicide
attempts through the mediation of hopelessness
and depressive symptoms.
Findings indicated that hopelessness
was more strongly linked with sexual
abuse in boys, while depression was
more strongly linked with high suicide
risk in girls.
Developmental theorists have hypothesized
that negative life events and
interpersonal difficulties may play an
important role in determining whether
childhood adversities contribute to the
onset of suicidal behavior. Case-control
research has suggested that interpersonal
conflict or separation during adulthood
may play a role in determining
whether neglectful and overprotective
parenting during childhood predicts
suicidal behavior during adulthood.44
Longitudinal studies have suggested
that low family cohesion, low family
expressiveness, and high family conflict
may mediate the association between
maternal depression and adolescent
suicidality,45 that adolescents' relationships
with their parents may moderate
the association between stressful life
events and depressive symptoms,46 and
that stressful life events may mediate
the association between certain types
of childhood adversity and risk for
suicidal behavior during adolescence or
early adulthood.47 These findings and
research indicating that disruption of
interpersonal relationships is a predominant
risk factor for suicide21,23 suggest
that suicide attempts may often be attributable
to severe chronic or episodic
interpersonal difficulties among persons
who had particularly problematic relationships
with their parents during
childhood.18,26
An interpersonal model of suicide,
based on research indicating that major
problems in interpersonal relationships
contribute to the onset of suicidality,
was developed by Johnson and
colleagues.48 This model hypothesizes
that childhood maltreatment and problematic
family relationships during
childhood contribute to a persistent
elevation in risk for suicide during
adolescence and adulthood. Persons
with a history of childhood maltreatment
or highly problematic family relationships
are hypothesized to be at
particularly elevated risk for suicidal
behavior when they experience severe
disruptions in current interpersonal relationships
during adolescence or adulthood
(Figure 1 [see June 2006 Psychiatric Times, page 33]). Research has provided
support for the interpersonal model of
suicide (Figure 2).48
Suicidal behavior is often attributable
to a combination of proximal and distal
risk factors. Several diathesis-stress theories
have been advanced regarding biologic,
psychological, and social diatheses
or vulnerability factors that may contribute
to increased risk for suicidal behavior
in the context of elevated stress
(chronic stress or stressful life events).
Proposed biologic diatheses include
genetic factors, prenatal factors, and
persistent alterations in neurobiologic
function and structure that may result
from severe traumatization during childhood.49,50 Learning and conditioning may
also contribute to the development of
diatheses for depression and suicidality,
such as learned helplessness, hopelessness,
and a persistent suppression
of the will to live.51-54
Treatment implications
Research on childhood adversities and
suicidality has important clinical implications.
Standard medical management
of the psychiatric disorders that are typically
associated with risk for suicidal
behavior (eg, major depressive disorder)
is appropriate and, in almost all
cases, necessary. A biopsychosocial
approach is likely to be particularly helpful
in assessing the suicidal patient and
determining the most appropriate treatment.
This approach includes ruling out
potential physiologic causes of psychiatric
problems (eg, thyroid disease),
determining whether pharmacotherapeutic
intervention is appropriate, and
assessing the likelihood of future
suicidal behavior. In addition to treating
the psychiatric symptoms that may
have helped precipitate a suicidal act,
clinicians should assess the history of
interpersonal problems and childhood
adversities that may have played an
important causative role in the development
of a patient's suicidal ideation
and behavior.
Following a systematic assessment
of a patient's history of adversities and
interpersonal difficulties, appropriate
treatment may often require psychotherapeutic
or psychosocial intervention.
Patients who are in a state of acute
despair about their life situation, based
on a history of profound interpersonal
difficulties (eg, failed romantic, peer,
or occupational relationships), often
originating in childhood adversities,
may need assistance in developing
improved interpersonal skills and
becoming more hopeful about the
future.
Thus, while it is important to effectively
treat the psychiatric disorders
that might precede suicidal behavior, it
is equally important to address interpersonal
problems or crises that may
lead to attempted suicide.22
Counseling has been found to play
an important role in suicide prevention
among individuals with and without a
history of suicidal behavior.55 Research
indicates that psychotherapeutic interventions
often play an important role
in the effective treatment of depressed
and suicidal persons. For example, a
recent large study demonstrated that
patients with chronic major depression
who had a history of childhood adversity
were more likely to respond to
psychotherapy than to medication.56
Some types of psychological interventions,
including cognitive therapy,
have been found to be effective in
preventing suicide attempts by persons
who have attempted suicide in the past.57
Another approach that may be helpful
in treating suicidal persons is dialectic
behavior therapy,58 an approach that
was developed for treating individuals with borderline personality disorder, a
condition often characterized by suicidal
or self-destructive behavior.
Community- and school-based suicide
prevention intervention programs
have been developed, although the effectiveness
of such programs has not yet
been well established.59-61 Follow-up
care is also likely to play an important
role in effective suicide prevention.62
Because persons who have previously
attempted suicide are at particularly
elevated risk for subsequent suicidal
behavior, monitoring a patient's functioning
and well-being during the first
few weeks and months after a suicide
attempt may be of critical importance.
Serious suicidal ideation is relatively
common in the general population. For
example, a recent large-scale epidemiologic
study has indicated that approximately
16% of the adolescents in the
United States may have had serious
thoughts of killing themselves within
the past year.63 It has been estimated
that approximately 3% of the adults in
the United States have had serious
suicidal ideation within the past year.64
Most persons in the general population
who have serious suicidal ideation do
not receive psychological or emotional
counseling.63,64 Improved recognition
and treatment of moderate to severe
suicidal ideation may contribute to a
reduction in the prevalence of suicidal
behavior.55
Conclusion
Research has supported the inference
that childhood adversities are associated
with elevated risk for suicidal
behavior during adolescence and adulthood.
Although several theories have
been developed to explain these associations,
further research is needed to
test these hypotheses and to identify
optimal interventions. Further research
is also needed to improve our understanding
of the causal mechanisms
underlying these associations.28 Acute
suicide prevention strategies should
focus on the effective treatment of psychiatric disorders that contributed
to attempted suicide and on the interpersonal,
occupational, and other
psychosocial crises that may precipitate
suicidal behavior.
Many patients who attempt suicide
are in a profound state of despair about
their life situation, and this kind of
despair often develops in persons who are hopeless about their ability to overcome
the challenges that they face.59 In
order to increase the patient's will to
live, and to decrease the patient's wish
to die, it is often necessary to assess
the history of childhood adversities
and interpersonal difficulties that may
have caused the patient to become
profoundly hopeless about the future.
In addition to assessing these types of
adversities, it is important to (1) establish
a strong therapeutic alliance with
the patient, (2) focus on helping the
patient become more hopeful about the
future, (3) maintain ongoing contact
with the patient, and (4) monitor the
patient's will to live, feelings of despair
and hopelessness, and ongoing suicidal
ideation.
Dr Hardt is with the Clinic for Psychosomatic
Medicine and Psychotherapy at the Johannes
Gutenberg University of Mainz in Germany. He
reports that he has no conflicts of interest
concerning the subject matter of this article.
Dr Johnson is associate professor of clinical
psychology in the department of psychiatry of
the College of Physicians and Surgeons at
Columbia University and a research scientist
at the New York State Psychiatric Institute in
New York City. He reports that he has no conflicts
of interest concerning the subject matter
of this article.
Ms Courtney is a researcher at the New York
State Psychiatric Institute in New York City. She
reports that she has no conflicts of interest
concerning the subject matter of this article.
Dr Sareen is with the department of psychiatry
and community health sciences at the
University of Manitoba in Canada. He reports
that he is on the speakers' bureau for
GlaxoSmithKline, Wyeth-Ayerst, Lundbeck,
and AstraZeneca.
Evidence-based References
- Brown GK, Ten Have T, Henriques GR, et al. Cognitive
therapy for the prevention of suicide attempts: a
randomized controlled trial. JAMA. 2005;294:563-
570.
- Simpson EB, Pistorello J, Begin A, et al. Use of dialectical
behavior therapy in a partial hospital program
for women with borderline personality disorder.
Psychiatr Serv. 1998;49:669-673.
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