Perceived social support buffers the impact of PTSD symptoms on suicidal behavior: Implications into suicide resilience research
Introduction
A considerable body of literature suggests that suicidal behavior lies on a continuum from covert suicidal thoughts to overt suicidal ideation/planning and suicide attempts [1], [2], [3], [4], [5], [6]. Exploring those factors which account for an individual's place on this continuum is an important area of research. The prevalence of suicidal behavior is heightened in those with Posttraumatic Stress Disorder (PTSD) [7]. Two recently conducted systematic reviews consistently reported a strong association between a PTSD diagnosis and suicidal behavior [8], [9]. More than half of those diagnosed with PTSD report suicidal thoughts [10], [11], [12], [13], [14] and as many as a quarter report suicide attempts [10], [12], [13].
Across a series of studies investigating the mechanisms of suicidal behavior in PTSD populations, an increased number and severity of PTSD symptoms have been found to be strongly associated with suicidal behavior [12], [13], [14]. Furthermore, there is empirical evidence that the presence and severity of PTSD symptoms are strong predictors of suicidal behavior among subclinical populations experiencing PTSD symptoms but do not fulfill the full criteria for a PTSD diagnosis. For example, Weaver et al [15] reported that increased frequency of PTSD symptoms together with depressive symptoms mediated the association between intimate partner violence and suicidal ideation in a sample of raped women. Leiner et al [16], using path analyses, found that the severity of PTSD symptoms mediated the association between intimate partner violence and suicidal ideation. Marshall et al [17] reported that individuals who experienced PTSD symptoms in the past month were significantly more likely to report current suicidal ideation compared to those who did not report PTSD symptoms in the past month. Additionally, the levels of suicidal ideation increased linearly with the number of PTSD symptoms experienced by the individuals [17]. Overall, the current literature findings suggest that heightened number and severity of PTSD symptoms are key risk factors for the development of suicidal behavior in both clinical populations suffering full PTSD and subclinical populations with subthreshold PTSD.
The vast majority of the studies in the general suicide literature have focused on investigating risk factors for suicidal behavior. A number of studies have advanced the previous literature by emphasizing the usefulness of identifying protective/resilience factors that reduce the risk for suicide [18], [19], [20]. Consistent with this, the concept of psychological resilience has received a growing attention lately [21], [22], [23], [24], [25]. The Schematic Appraisals Model of Suicide (SAMS) [26] is a recently proposed theoretical model of suicide which provides a useful framework under which the mechanisms conferring resilience to suicide can be theoretically understood and empirically investigated [4]. The SAMS model emphasizes the importance of an appraisal system and suggests that two appraisal subsystems are critical in relation to suicidal behavior. First, the SAMS model argues that negative situation appraisals are key components of suicidal behavior. When the individual's situation appraisals are geared towards the negative, feelings of defeat and entrapment emerge, which in turn can lead to suicidal behavior. Subjective negative evaluations/perceptions of psychiatric illness or clinical symptoms are examples of these negative situation appraisals. Second, the SAMS model proposes a self-appraisal system which encompasses subjective evaluations regarding personal attributes, problem solving skills or availability of social support and rescue factors. These self-appraisals are thought to interact and to strengthen situation appraisals. This suggests that negative self-appraisals may result in more negative situation appraisals and increase the likelihood of suicidal thoughts and behaviours. In contrast, positive self-appraisals are thought to provide a source of resilience to suicide [26]. More recently, Johnson and colleagues have conceptualized positive self-appraisals as potential resilience factors, which protect individuals against the development of suicidal behaviors because they buffer the impact of factors which increase the risk for suicide [4]. Furthermore, it has been suggested that resilience factors coexist with risk factors in two separate dimensions and that resilience factors moderate or buffer the impact of risk factors on suicide [23]. Finally, it has been suggested that individuals with high perceived social support are more aware of the availability of external resources and establish the possibility of being ‘rescued’ [26], [27].
On the basis of these theoretical developments [23], [26], [27] one core prediction is that resilience factors would be inversely associated with suicidal behavior and more importantly would buffer the impact of risk factors on suicidal behavior. The outcomes of two recent studies fully supported this buffering hypothesis. Johnson et al [4] showed that a general measure of positive self-appraisals regarding the ability to cope with difficult emotions, manage external situations, and utilize social support moderated the impact of stressful life events on suicidal behavior in a student sample. The same research team [3] found that positive self-appraisals of the ability to cope with negative emotions moderated the association between hopelessness and suicidal ideation among psychotic patients. There is a clear gap in the literature examining resilience to suicide in those experiencing the symptoms of PTSD with a focus on social support. However some studies in the context of PTSD offer a reason for optimism with respect to identifying resilience to suicide. In particular, some studies have demonstrated an inverse relationship between high levels of social support and the PTSD experience [28], [29]. High perceived social support has been associated with lower PTSD severity [30], [31] and better psychological treatment outcomes [32]. In contrast, low perceived social support has emerged as a strong predictor of the subsequent presence and severity of PTSD symptoms [29], [33], [34]. Additionally, an inverse relationship between heightened perceived social support and suicidal behavior has been found across three studies using PTSD populations [14], [35], [36].
To sum up, high levels perceived social support have been linked with positive outcomes in those with PTSD including a lower risk for suicide. That said, to date, no previous study has investigated whether perceived social support confers resilience to suicide in those with PTSD. The investigation of resilience or buffering factors in PTSD is crucial because resilience factors, such as perceived social support, may protect individuals from developing suicidal behavior by buffering the pernicious impact of PTSD symptoms. Thus, the current study aimed to examine whether high levels of perceived social support have a buffering impact on suicidal behavior in a sample of trauma victims reporting a range of PTSD symptoms in the past month. Trauma victims with full or subthreshold PTSD report increased levels of suicidal thoughts and behaviors [7], [17], [37] but, currently, there is no empirical evidence regarding the existence of resilience factors in this group. Since number and severity of PTSD symptoms have been found to be strongly associated with increased frequency of suicidal behaviors [12], [14], [16], [17], it was predicted that positive perceptions of social support would buffer or moderate the impact of increased number and severity of PTSD symptoms on suicidal behavior.
Section snippets
Sample and procedure
Participants were recruited using adverts (i.e., newspaper advertising, online advertising in the University of Manchester (UK), posters in mental health services based in Manchester, such as, Victim Support and the Rape Crisis Centre) asking for people who have experienced a traumatic event (i.e., crime, physical threat, serious accident, military combat, natural disaster, terrorist attack, diagnosed with a life-threatening illness) in the past and have been affected by it to volunteer.
Sample characteristics
A total of 66 participants were recruited into the study and completed measures of PTSD and social support. Eight participants were excluded from the study because they did not present any PTSD symptoms in the past month based on the PDS scale. We also excluded two participants from the current analyses due to substantial missing data. Thus, the analyses were based on analyzing data from 56 individuals (mean age = 29.1, SD = 11.5) who experienced at least one PTSD symptom in the past month. The
Discussion
The overarching aim of this study was to investigate whether heightened levels of perceived social support buffered individuals with PTSD symptoms against the development of suicidal thoughts and behaviors. The outcomes of the analyses demonstrated that perceived social support moderated the impact of the number and severity of PTSD symptoms on suicidal behavior. For those individuals who reported high levels of perceived social support, their levels of suicidal behavior did not increase
Acknowledgment
The authors would like to thank the Foundation for Education and European Culture (IPEP) for funding the PhD research of the first author.
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