Elsevier

Comprehensive Psychiatry

Volume 51, Issue 2, March–April 2010, Pages 121-129
Comprehensive Psychiatry

Is impulsivity a link between childhood abuse and suicide?

https://doi.org/10.1016/j.comppsych.2009.05.003Get rights and content

Abstract

Childhood abuse and neglect are known to affect psychological states through behavioral, emotional, and cognitive pathways. They increase the risk of having psychiatric diseases in adulthood and have been considered risk factors for suicidal behavior in all diagnostic categories. Early, prolonged, and severe trauma is also known to increase impulsivity, diminishing the capacity of the brain to inhibit negative actions and to control and modulate emotions. Many neurobiological studies hold that childhood maltreatment may lead to a persistent failure of the inhibitory processes ruled mainly by the frontal cortex over a fear-motivated hyperresponsive limbic system. Multiple neurotransmitters and hormones are involved in the stress response, but, to our knowledge, the two major biological consequences of the chronic exposure to trauma are the hypofunction of the serotonergic system and changes in the hypothalamic-pituitary-adrenal axis function. Some of these findings overlap with the neurobiological features of impulsivity and of suicidal behavior. Impulsivity has also been said to be both a consequence of trauma and a risk factor for the development of a pathological response to trauma. Thus, we suggest that impulsivity could be one of the links between childhood trauma and suicidal behavior. Prevention of childhood abuse could significantly reduce suicidal behavior in adolescents and adults, in part, through a decrease in the frequency of impulsive behaviors in the future.

Introduction

Suicide is a major cause of death in the United States and around the world. In 2002, an estimated 877 000 lives were lost worldwide through suicide [1]. It is the third leading cause of death in young people in the United States and the leading cause of death in young adults in China, Sweden, Australia, and New Zealand among other countries [2]. There are 10 to 20 suicide attempts for every completed suicide [2], [3].

Impulsivity comprises a wide spectrum of behaviors characterized by quick and nonplanned reaction to external or internal stimuli, without taking into account the possible negative consequences for the individual or for others [4]. It can be considered as a personality trait or as a behavior or state (ie, impulsive action) [5]. Many psychological instruments have been designed to measure impulsivity, sometimes leading to difficulties in the comparison of results between different studies [6].

The relationship between impulsive behavior and suicide attempts can be thought of as having two dimensions [5], [7]: a suicide attempt can be impulsive or not, and the suicide attempter can have impulsive traits or not. These 2 dimensions may not completely overlap or be equivalent. Impulsivity as a trait has been identified as a key factor in risk of suicidal behavior in adolescent [8], [9], [10], [11] and adult patients [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22]. Although it should be recalled that not all suicides are highly impulsive, many of the known clinical and behavioral risk factors commonly associated with suicide are particularly valid for impulsive suicide completers [23], [24].

Section snippets

Definition and prevalence of childhood abuse

Child abuse can be considered a type of childhood trauma and is a culturally defined phenomenon. It has been described as “the violation of rights of a child to be protected, from parents unable to cope at a level assumed to be reasonable by the society in which they reside” [25]. When talking about “reasonable,” many differences can be found within and between societies [26]. The World Health Organization clarifies that “child abuse or maltreatment constitutes all forms of physical and/or

Neurobiological effects of childhood abuse and neglect

The brain interprets experiences as threatening or nonthreatening and controls behavioral and physiological responses to each situation [37]. After the perception of an acute stressful event, there is a cascade of changes in the nervous, cardiovascular, endocrine, and immune systems [38]. The main psychobiological circuits involved in emotions related to fear and anger are primitive and ancient from an evolutionary perspective [39]. Therefore, they have their basis in ancient subcortical

Childhood trauma and suicide

Prolonged and severe trauma, particularly trauma that occurs early in the life cycle, tends to result in a chronic inability to modulate emotions, thus augmenting the risk of getting involved in indiscriminate relationships with others in which old traumas are, somehow, reenacted [36], [76], [77], [78], [79], [80], [81] or, in some cases, leading to the loss of social bonds [82]. It may also lead to new traumas as a result of psychiatric pathology, maladaptive personality features, impulsive

Childhood abuse and impulsivity

Impulsivity has been related to trauma and, specifically, to PTSD in 2 different ways. Impulsivity (mainly as a personality trait) has been said to be a consequence of trauma principally when experienced in childhood or in the adolescent period, maybe because of an acquired inability of the brain to inhibit some negative actions [36]. However, impulsivity (both as a state and as a trait) has been also considered to be a risk factor to be exposed to trauma and to develop PTSD [110], [111], [112]

Preventing childhood maltreatment and its consequences

Public health interventions on childhood abuse and neglect should be based on 3 levels of prevention, defined by their temporal aspect: (a) primary prevention, which approaches the aim to prevent violence before it occurs; (b) secondary prevention, which focuses on the more immediate responses to violence; and (c) tertiary prevention, which concentrates on long-term care in the wake of violence, such as rehabilitation and reintegration, and attempts to lessen trauma or reduce the long-term

Conclusions

There is a growing evidence of the effects of childhood trauma in the developing brain of children and adolescents [36]. One of these effects is an increased impulsivity related to an acquired inability of the brain to inhibit some negative actions [36]. Childhood abuse and neglect may result in a chronic inability to modulate emotions, thus augmenting the risk of getting involved in indiscriminate relationships with others in which old traumas may be repeated [36], [76], [77], [78], [79], [80]

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    • Impulsivity as a mediator between childhood maltreatment and suicidal behavior: A systematic review and meta-analysis

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      About 30% of the population has experienced childhood maltreatment (Angelakis et al., 2019). Several previous reviews and meta-analyses have studied the relationship between childhood maltreatment and the risk of suicide or suicidal behavior in both adult and adolescent populations (Angelakis et al., 2019; Braquehais et al., 2010; Brodsky, 2016; Liu et al., 2018; Makhija and Sher, 2007; Makhija, 2007; Miller et al., 2013; Serafini et al., 2017; Zatti et al., 2017). In 2017, Zatti et al. conclude that physical, emotional, and sexual abuse, physical neglect, and exposure to domestic violence in childhood are risk factors for future autolytic intent (Zatti et al., 2017).

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    Dr Braquehais' work was supported by the Alicia Koplowitz Foundation via one 2008 Short-Term Visiting Fellowship at the New York Psychiatric Institute (Columbia University).

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