hich symptoms of post-traumatic stress disorder are associatedith suicide attempts?
eynep M.H. Selamana, Hayley K. Chartrandb, James M. Boltona,b,c, Jitender Sareena,b,c,∗
Department of Psychiatry, Faculty of Medicine, University of Manitoba, PZ430-771 Bannatyne Avenue, Winnipeg, MB R3E 3N4, CanadaDepartment of Psychology, University of Manitoba, P404 Duff Roblin Building, 190 Dysart Road, Winnipeg, MB R3T 2N2, CanadaDepartment of Community Health Sciences, University of Manitoba, S113 Medical Services Building, 750 Bannatyne Avenue, Winnipeg, MB R3E 0W3,anada
r t i c l e i n f o
rticle history:eceived 5 May 2013eceived in revised form3 December 2013ccepted 16 December 2013
a b s t r a c t
Individuals with post-traumatic stress disorder are at increased risk for suicide attempts. The presentstudy aimed to determine which of the specific DSM-IV symptoms of post-traumatic stress disorder(PTSD) are independently associated with suicide attempts. Data came from Wave 2 of the NationalEpidemiologic Survey on Alcohol and Related Conditions (NESARC). The NESARC has a sample size ofN = 34 653. The full sample size included in analyses was 2322 individuals with PTSD. Among individ-
uals with lifetime PTSD, after adjusting for sociodemographic factors, as well as any mood, substance,personality, or anxiety disorder (excluding PTSD), increasing numbers of re-experiencing and avoidancesymptoms were significantly correlated with suicide attempts. Of the specific symptoms, having phys-ical reactions by reminders of the trauma, being unable to recall some part of it, and having the senseof a foreshortened future, were all associated with suicide attempts. These findings will help extend ourunderstanding of the elevated risk for suicide attempts in individuals with PTSD.
. Introduction
There has been an increasing interest in the relationshipetween post-traumatic stress disorder (PTSD) and suicide. Sev-ral studies have consistently shown that PTSD is associated withncreased likelihood of suicidal behavior (Cougle, Keough, Riccardi,
998). In a study by Sareen et al. (2005), which examined the rela-ionship of individual anxiety disorders with both suicidal ideationnd suicide attempts in a nationally representative sample, it was
ound that PTSD was the only anxiety disorder that was indepen-ently associated with both suicidal ideation and suicide attempts.
study by Nepon et al. (2010) which adjusted for all 10 DSM-IV
∗ Corresponding author at: Community Health Sciences and Psychology, Depart-ent of Psychiatry, Faculty of Medicine, University of Manitoba, PZ430 – 771
personality disorders, as well as Axis I disorders, found that bothPTSD and panic disorder were significantly associated with lifetimesuicide attempts.
There is a small body of literature that has examined therelationship between the three symptom clusters of PTSD (re-experiencing, avoidance, and hyperarousal) and suicidal behavior.However, there is no clear evidence as to which of these clus-ters are more or less associated with suicide attempts. A studyby Bell and Nye (2007) which examined a sample of 50 Vietnamcombat veterans found that the re-experiencing symptom clusterwas more strongly associated with suicidal ideation, whereas thehyperarousal and avoidance symptoms were not. This study, how-ever, did not examine suicide attempts as an outcome. One otherstudy by Ben-Ya’acov and Amir (2004) examined the relationshipbetween PTSD symptoms and suicide risk, finding that in a com-munity sample of 103 men with no known psychopathology, highlevels of arousal symptoms may increase suicide risk.
Both of the studies were limited by small sample sizes and theuse of community or veteran samples and therefore may have beeninfluenced by selection bias. Suicide attempts have been consis-tently identified as one of the strongest risk factors for eventualsuicide (Tidemalm, Langstrom, Lichtenstein, & Runeson, 2008), and
therefore it is important to examine their relationship with PTSDsymptoms. To the best of our knowledge, our study will be thefirst to examine PTSD symptom clusters as well as individual PTSDsymptoms in relation to suicide attempts.
Fig. 1. Flowchart of sample studied (N = 2322). Those with a suicide attempt afteroa
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east, Midwest, South, and West), marital status (married or
r in the same year as the diagnosis of PTSD (n = 222) were compared to those with diagnosis of PTSD and no suicide attempt (n = 2100).
The aim of our study was to address these limitations using datarom the National Epidemiologic Survey of Alcohol and Relatedonditions (NESARC) to determine the relationship between sui-ide attempts and the three DSM-IV symptom clusters of PTSDre-experiencing, avoidance, and hyperarousal). Secondary objec-ives were to determine whether any of the individual symptomsisted under each symptom cluster was independently associated
ith suicide attempts.Based on previous literature, we hypothesized that the hyper-
rousal and re-experiencing symptoms would be more stronglyssociated with suicide attempts than would avoidance symptomsBell & Nye, 2007; Ben-Ya’acov & Amir, 2004). Investigating theelationship between specific symptoms and suicide attempts willelp refine and extend our understanding of the elevated risk ofuicidal behavior observed with PTSD.
. Methods
.1. Sample
Data were obtained from Wave 2 (2004–2005) of the Nationalpidemiologic Survey of Alcohol and Related Conditions (NESARC).he NESARC is a nationally representative survey of noninstitution-lized US civilians aged 20 and over. All variables used in this studyame from the Wave 2 assessment. Interviews were administeredn person, and the overall response rate was 70.2%. The sample sizes N = 34 653. As demonstrated in Fig. 1, of the 34 653 participants,463 met criteria for lifetime PTSD and 360 had both lifetime PTSDnd SA. Of the 360 that met criteria for PTSD and answered ‘yes’o suicide attempts, 128 were excluded from the sample becausehe suicide attempt preceded the diagnosis of PTSD. Our analy-
es included the n = 2100 participants with PTSD and no suicidettempts and the n = 222 participants who attempted suicide afterhe diagnosis of PTSD.
ty Disorders 28 (2014) 246–251 247
2.2. Mental disorders
Lay interviewers used the Alcohol Use Disorders and AssociatedDisabilities Interview Schedule IV (AUDADIS-IV) to make Diagnosticand Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnoses, including PTSD. Other Axis 1 disorders were alsoassessed using the AUDADIS-IV. These included any mood disor-ders (depression, dysthymia, mania, and hypomania), any anxietydisorders (generalized anxiety disorder, social anxiety disorder,specific phobia, and panic disorder), any personality disorders, andany substance use or alcohol use disorders.
2.3. PTSD symptoms
PTSD symptoms were assessed by matching the DSM-IV crite-ria for the individual symptoms under each of the three symptomclusters with the questions asked in the NESARC questionnaire.Responses were coded as either ‘yes’ or ‘no’.
For example, the 5 DSM-IV symptoms categorized under there-experiencing symptom cluster were assessed with 6 differ-ent NESARC survey questions. The symptoms described in theDSM-IV as ‘acting or feeling as if the traumatic event were recur-ring’ and ‘intense psychological distress at exposure to internal orexternal cues’ were assessed by asking respondents three differ-ent questions: After that worst event happened did you (1) Feelthat you were reliving (that/that worst) event or that it was hap-pening all over again?; (2) Find yourself acting as if (that/thatworst) event was happening again, for example, reacting to sightsor sounds like the ones you heard when it happened?; and (3)Get very upset when you were reminded of (that/that worst)event?
The seven DSM-IV symptoms that comprised the avoidancecluster were assessed with 8 different NESARC questions. Thesymptom described in the DSM-IV as ‘efforts to avoid thoughts,feelings, or conversations associated with the trauma’ wereassessed with the following two questions: After that worst eventhappened did you (1) Try to stop thinking about or feeling anythingabout (that/that worst) event?; and (2) Try to avoid conversationsthat had anything to do with it?
The 5 DSM-IV symptoms that comprised the hyperarousalsymptom cluster were assessed with 5 different NESARC ques-tions. For example, sleep problems were assessed by asking ‘After(that/that worst) event happened did you have trouble fallingasleep or staying asleep?’
The PTSD symptom clusters (re-experiencing, avoidance, andhyperarousal) were included in analyses as continuous variablesbased on the number of symptoms endorsed for each cluster.
2.4. Suicide attempts
Suicide attempts were assessed in Wave 2 of the NESARC byasking participants the following question: ‘In your entire life didyou ever attempt suicide?’ Responses were coded as either ‘yes’ or‘no’.
2.5. Sociodemographic factors
The sociodemographic variables included in the analyses wereage (20–29, 30–44, 45–64, and ≥65 years), income ($0–$19 999,$20 000–$34 999, $35 000–$59 999, and ≥$60 000), region (North-
cohabiting, divorced/separated/widowed, and never married), andracial/ethnic identity (White, Black, American Indian or Alaskan,Asian or Hawaiian, and Hispanic).
2 Anxiety Disorders 28 (2014) 246–251
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Table 1Characteristics of the lifetime PTSD sample with and without suicide attempts.
Lifetime PTSD sample(N = 2463)n(%)a
No suicide attempt(N = 2100)
Suicide attempt afterPTSD diagnosis(N = 222)
Socio-demographicsGender
Male 592(31.7) 56(26.2)Female 1508(68.3) 166(73.9)
To examine the relationship between suicide attempts andndividual PTSD symptoms, we used multiple logistic regression.he individual PTSD symptoms were the predictor variables, anduicide attempt was the outcome variable. The reference groupncluded people with a diagnosis of PTSD and no lifetime sui-ide attempt. There were three different models: (1) unadjustedith all individual PTSD symptoms entered simultaneously into
he model, (2) adjusted for sociodemographics, and (3) adjustedor sociodemographics, any mood disorder, any substance use dis-rder, any personality disorder, and any anxiety disorder (exceptTSD). An alpha level of 0.05 was used to determine statisticalignificance for all analyses. In addition, we used multiple logis-ic regression to determine whether an increasing number ofymptoms of a specific PTSD symptom cluster (re-experiencing,voidance, or hyperarousal) was independently associated withuicide attempts (reference group: PTSD and no suicide attempts).ontinuous symptom count variables for the different PTSD clus-ers were entered simultaneously and the same covariates weresed as above for these analyses as well.
We conducted all statistical analyses using Software for Sur-ey Data Analyses (SUDAAN) (Research Triangle Institute, 2009),sing the appropriate statistical weights and stratification variablesrovided by the NESARC to ensure the representativeness of theata to the United States population. The Taylor Series Lineariza-ion method was used in the SUDAAN software system to performhe necessary estimation of design-based standard errors to reflecthe complex multistage sampling design of the NESARC.
. Results
Table 1 compares the demographics and mental disorders inhe PTSD with no suicide attempt group and the group with suicidettempt after a diagnosis of PTSD. Prevalence of lifetime mental dis-rders in the group that attempted suicide with a diagnosis of PTSDas increased as compared to the PTSD with no suicide attempt
roup.Table 2 identifies the different NESARC questions used to eval-
ate the specific DSM IV symptoms of PTSD, as well as thessociations between the individual PTSD symptoms and sui-ide attempts. Three of the 19 individual PTSD symptoms wereignificantly associated with SA even after adjusting for sociodemo-raphics, other Axis I disorders, and personality disorders. Amonghose with PTSD, the individual symptoms ‘get physical reactionsy reminder’ (AOR = 2.33; 95% CI: 1.33–4.08), ‘unable to recall someart of it’ (AOR = 1.55; 95% CI: 1.03–2.34), and ‘sense of a foreshort-ned future’ (AOR = 1.57; 95% CI: 1.02–2.42) were associated with auicide attempt following or in the same year as a PTSD diagnosis,ompared to those with PTSD and no suicide attempt.
Table 3 demonstrates the relationship of suicide attempts withhe three PTSD symptom clusters. After adjusting for sociode-
ographics, and any comorbid mood, anxiety (minus PTSD),ersonality, and substance disorders, both the re-experiencing andvoidance symptom clusters were significantly associated withuicide attempts. Adjusted odds ratios were (AOR = 1.24; 95% CI:.04–1.48) and (AOR = 1.25; 95% CI: 1.08–1.44), respectively.
. Discussion
To the best of our knowledge, the present study is the first that
xamines the associations between the specific symptoms of DSM-V PTSD and suicide attempts. We found that among the threeTSD symptom clusters, symptoms of re-experiencing were sig-ificantly associated with suicide attempts, and contrary to our
Any personality disorder 953(44.9) 179(81.4)
a n’s are unweighted, percentages are weighted.
original hypothesis avoidance symptoms were also significantlyassociated with suicide attempts. This was true even after adjustingfor sociodemographics, any mood, any substance, any personality,and any anxiety disorder (excluding PTSD). Specific symptoms suchas ‘get physical reactions by reminder’, ‘unable to recall some partof it [the traumatic event]’, and ‘sense of a foreshortened future,’in individuals with PTSD were found to be significantly associatedwith suicide attempts following or in the same year as a PTSD diag-nosis. As individuals with PTSD have been shown to be at higherrisk of attempting suicide (Tidemalm et al., 2008) and a strong riskfactor for attempting suicide is a prior attempt, it is important to bemindful of those who experience the specific symptoms associatedwith suicide attempts.
The perception of defeat and entrapment in the SchematicAppraisal Model of Suicide (Johnson, Gooding, & Tarrier, 2008)has been shown to be a key psychological mechanism leading tosuicidal behavior (Johnson et al., 2008). The association betweendefeat and entrapment and suicidal behavior was also shownby Panagioti, Gooding, Taylor, and Tarrier (2012) and Panagioti,Gooding, Taylor, and Tarrier (2013) to be strongly positive evenafter controlling for comorbid depression. The pathway in whichre-experiencing and avoidance symptoms may lead to suicide
attempts can be explained by examining this association in individ-uals diagnosed with PTSD. Individuals with PTSD who experiencephysical reactions by reminders of the traumatic event have
Z.M.H. Selaman et al. / Journal of Anxiety Disorders 28 (2014) 246–251 249
Table 2Individual PTSD symptoms and suicide attempts after PTSD diagnosis among those with PTSD.
Questions from the NESARC traumaticexperiences questionnaire
DSM IV symptoms No suicide attempts(n = 2100) n(%)a
4. Find yourself acting as if (that/thatworst) event was happening again, forexample, reacting to sights or soundslike the ones you heard when ithappened?
5. Get very upset when you werereminded of (that/that worst) event?
Get upset by reminder 1747(84.6) 208(93.4) 1.56(0.68–3.55) 1.33(0.58–3.03)
6. Have any physical reactions whensomething reminded you of (that/thatworst) event, like breaking out in asweat, breathing fast, or feeling yourheart pounding?
AOR: Adjusted for socio-demographic variables, any mood disorder, any anxiety disorder (minus PTSD), any substance use disorder and any personality disorder.*
icide
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*p < 0.01, *p < 0.05.a Percentages are column percents. For example, among those who attempted su
eightened physiological reactivity as compared to those whoave experienced a similar traumatic event but do not have PTSDBlanchard, Kolb, Taylor, & Wittrock, 1989; Keane et al., 1998;
itman, Orr, Forgue, & de Jong, 1987). These physiologic reactionsre largely mediated by an increase in sympathetic activity andlevated catecholamines, and result when the individual is con-ronted by reminders of the traumatic event (Bedi & Arora, 2007).
after PTSD diagnosis, 90.8% had bad dreams.
These physiologic reactions and autonomic hyperarousal result ina perception of ongoing threat or danger, a phenomenon that hasbeen described in both PTSD and panic disorder (Barlow, 2002). This
perception of ongoing threat can result in overwhelming feelingsof defeat and entrapment, as well as increased anxiety sensitiv-ity, or fear of arousal related physical and psychological sensation(Fedoroff, Taylor, & Asmundson, 2000; McNally, 2002). Increased
250 Z.M.H. Selaman et al. / Journal of Anxie
Table 3PTSD symptom clusters and suicide attempts after PTSD diagnosis among those withPTSD.
AOR: Adjusted for sociodemographics, any mood disorder, any anxiety disorder(minus PTSD), any substance use disorder, and any personality disorder.
*** p < .001.
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nxiety sensitivity serves to maintain and exacerbate this percep-ion of entrapment, which might in turn exacerbate the symptomf sensing a foreshortened future (Fedoroff et al., 2000). As shownn Barlow’s (2002) positive feedback, catastrophic cognitions arehen amplified as a result of this limbic-autonomic arousal, lead-ng to suicidal ideation. Suicide attempts can then be driven by theombination of both suicidal ideation and this heightened arousalBarlow, 2002).
Other avoidance symptoms such as ‘unable to recall parts of theraumatic event’ may provide a coping mechanism for individualsith PTSD to deal with the intrusiveness of the re-experiencing
ymptoms (Panagioti, Gooding, Dunn, & Tarrier, 2011). Thesevoidant coping mechanisms may in turn contribute to the path to
suicide attempt through association with poorer social functionnd negative affect (Panagioti et al., 2011).
The current findings should be interpreted within the contextf certain limitations. The first limitation being that the NESARC isross-sectional, therefore, we are unable to make causal inferencesbout PTSD symptoms causing suicide attempts. Second, we werenly able to assess the presence or absence of PTSD symptoms,nd not the severity of these symptoms. Third, although effortsere made to improve the temporal relationship between PTSD
nd suicide attempts by limiting the analyses that compared suicidettempts to no suicide attempts to those who attempted suicideollowing PTSD diagnosis or in the same year, it was still possi-le that the suicide attempt occurred before the PTSD diagnosis ifhe attempt happened that same year. Furthermore, we have nonformation about the lethality of the suicide attempts. Addition-lly, the interviews for the NESARC were conducted by trained laynterviewers as opposed to clinicians, and diagnoses were gener-ted by computer algorithm. Finally, participants’ responses maye influenced by recall bias.
. Conclusions
It is important for clinicians to identify individuals withTSD who are at higher risk for suicide attempts. The resultsf this cross-sectional study suggest that certain symptoms ofTSD, such as symptoms from the avoidance and re-experiencingymptom clusters, may predict suicide attempts. However, fur-her studies with longitudinal designs are needed to clarifyhe exact relationship between PTSD symptoms and suicidettempts.
cknowledgements
The authors would like to thank Ms. Sarah Marie Raposo, B.A.
Hons.) for editing this manuscript. Hayley Chartrand is supportedy a University of Manitoba Graduate Fellowship and a Manitobaraduate Scholarship. Dr. Bolton is supported by a Manitobaealth Research Council Establishment grant and a CIHR New
ty Disorders 28 (2014) 246–251
Investigator Award. Dr. Sareen is supported by a Manitoba HealthResearch Council grant.
References
Barlow, D. H. (2002). Anxiety and its disorders: the nature and treatment of anxiety andpanic (2nd ed.). New York, NY: Guilford Press.
Bedi, U. S., & Arora, R. (2007). Cardiovascular manifestations of post-traumatic stress disorder. Journal of the National Medical Association, 99(6),642–649.
Bell, J. B., & Nye, E. C. (2007). Specific symptoms predict suicidal ideation in Vietnamcombat veterans with chronic post-traumatic stress disorder. Military Medicine,172(11), 1144–1147.
Ben-Ya’acov, Y., & Amir, M. (2004). Post-traumatic symptoms and sui-cide risk. Personality and Individual Differences, 36(6), 1257–1264.http://dx.doi.org/10.1016/S0191-8869(03)00003-5
Blanchard, E. B., Kolb, L. C., Taylor, A. E., & Wittrock, D. A. (1989).Cardiac response to relevant stimuli as an adjunct in diagnosing post-traumatic stress disorder: replication and extension. Behavior Therapy, 20(4),535–543.
Cougle, J. R., Keough, M. E., Riccardi, C. J., & Sachs-Ericsson, N. (2009).Anxiety disorders and suicidality in the national comorbiditysurvey-replication. Journal of Psychiatric Research, 43(9), 825–829.http://dx.doi.org/10.1016/j.jpsychires.2008.12.004
Davidson, J. R., Hughes, D., Blazer, D. G., & George, L. K. (1991). Post-traumatic stressdisorder in the community: an epidemiological study. Psychological Medicine,21(3), 713–721.
Fedoroff, I. C., Taylor, S., Asmundson, G. J. G., & Koch, W. J. (2000). Cognitive factors intraumatic stress reactions: predicting PTSD symptoms from anxiety sensitivityand beliefs about harmful events. Behavioural and Cognitive Psychotherapy, 28(1),5–15.
Ferrada-Noli, M., Asberg, M., Ormstad, K., Lundin, T., & Sundbom, E. (1998). Suicidalbehavior after severe trauma. Part 1. PTSD diagnoses, psychiatric comorbid-ity and assessments of suicidal behavior. Journal of Traumatic Stress, 11(1),103–112.
Helzer, J. E., Robins, L. N., & McEvoy, L. (1987). Post-traumatic stress disorder in thegeneral population: findings of the epidemiologic catchment area survey. TheNew England Journal of Medicine, 317(26), 1630–1634.
Johnson, J., Gooding, P., & Tarrier, N. (2008). Suicide risk in schizophrenia: explana-tory models and clinical implications, the schematic appraisal model of suicide(SAMS). Psychology and Psychotherapy: Theory, Research and Practice, 81(1),55–77. http://dx.doi.org/10.1348/147608307X244996
Keane, T. M., Kolb, L. C., Kaloupek, D. G., Orr, S. P., Blanchard, E. B., Thomas, R.G., et al. (1998). Utility of psychophysiology measurement in the diagnosis ofpost-traumatic stress disorder: results from a department of veteran’s affairscooperative study. Journal of Consulting and Clinical Psychology, 66(6), 914–923.http://dx.doi.org/10.1037/0022-006X.66.6.914
Kessler, R. C., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C. B. (1995). Post-traumatic stress disorder in the national comorbidity survey. Archives of GeneralPsychiatry, 52(12), 1048–1060.
Kotler, M., Iancu, I., Efroni, R., & Amir, M. (2001). Anger, impulsivity,social support, and suicide risk in patients with post-traumatic stressdisorder. Journal of Nervous and Mental Disease, 189(3), 162–167.http://dx.doi.org/10.1097/00005053-200103000-00004
McNally, R. J. (2002). Anxiety sensitivity and panic disorder. Biological Psychiatry,52(10), 938–946. http://dx.doi.org/10.1016/S0006-3223(02)01475-0
Nepon, J., Belik, S., Bolton, J., & Sareen, J. (2010). The relationship between anxietydisorders and suicide attempts: findings from the national epidemiologic sur-vey on alcohol and related conditions. Depression and Anxiety, 27(9), 791–798.http://dx.doi.org/10.1002/da.20674
Panagioti, M., Gooding, P. A., Dunn, G., & Tarrier, N. (2011). Pathways to suicidalbehavior in post-traumatic stress disorder. Journal of Traumatic Stress, 24(2),137–145. http://dx.doi.org/10.1002/jts.20627
Panagioti, M., Gooding, P., Taylor, P. J., & Tarrier, N. (2012). Negative self appraisalsand suicidal behavior among trauma victims experiencing PTSD symptoms: themediating role of defeat and entrapment. Depression and Anxiety, 29(3), 187–194.http://dx.doi.org/10.1002/da.21917
Panagioti, M., Gooding, P., Taylor, P. J., & Tarrier, N. (2013). A modelof suicidal behavior in post-traumatic stress disorder (ptsd): themediating role of defeat and entrapment. Psychiatry Research,http://dx.doi.org/10.1016/j.psychres.2013.02.018
Pitman, R. K., Orr, S. P., Forgue, D. F., & de Jong, J. (1987). Psychophys-iologic assessment of post-traumatic stress disorder imagery invietnam combat veterans. Archives of General Psychiatry, 44(11),970–975.
Research Triangle Institute. (2009). Software for Survey Data Analysis(SUDAAN), Version 10.0.1. Research Triangle Park, NC: Research Triangle
Sareen, J., Houlahan, T., Cox, B. J., & Asmundson, G. J. G. (2005). Anxiety disor-ders associated with suicidal ideation and suicide attempts in the nationalcomorbidity survey. Journal of Nervous and Mental Disease, 193(7), 450–454.http://dx.doi.org/10.1097/01.nmd.0000168263.89652.6b
young adults. Archives of General Psychiatry, 66(3), 305–311. http://dx.doi.org/10.1001/archgenpsychiatry.2008.557
Wunderlich, U., Bronisch, T., & Wittchen, H. (1998). Comorbidity patterns in ado-lescents and young adults with sucide attempts. European Archives of Psychiatry
Z.M.H. Selaman et al. / Journal of
arrier, N., & Gregg, L. (2004). Suicide risk in civilian PTSD patients: predictors ofsuicidal ideation, planning and attempts. Social Psychiatry and Psychiatric Epi-demiology, 39(8), 655–661. http://dx.doi.org/10.1007/s00127-004-0799-4
idemalm, D., Långström, N., Lichtenstein, P., & Runeson, B. (2008). Risk of sui-
cide after suicide attempt according to coexisting psychiatric disorder: Swedishcohort study with long term follow-up. BMJ: British Medical Journal, 337(7682)http://dx.doi.org/10.1136/bmj.a2205
ilcox, H. C., Storr, C. L., & Breslau, N. (2009). Post-traumatic stress dis-order and suicide attempts in a community sample of urban American
