We’re going to do one more baby hit of worthlessness research, just to drive the point home. I’ve been claiming worthlessness is the driver of everything we know as unresponsive PTSD or typical CPTSD – all the way down to the worst outcomes commonly linked with high ACE scores like institutionalization and early death.
Today let’s make sure I’m not exaggerating on the detrimentality of comparative worth.
Feelings of worthlessness, traumatic experience, and their comorbidity in relation to lifetime suicide attempt in community adults with major depressive disorder
Hong Jin Jeon a,b,c , Jong-Ik Park d , Maurizio Fava c , David Mischoulon c , Jee Hoon Sohn e , Sujeong Seong e , Jee Eun Park e , Ikki Yoo a , Maeng Je Cho
Journal of affective disorders
2014
Suicide is not a simple “A leads to B” event. It condensates from the convergence of several factors which generally have relationship to each other. For instance, depression and substance misuse support each other and act as suicide attempt risk factors. One could also step back a few feet and suspect that trauma might be related to both, potentially through destructive perspectives that might connect the bunch. So it’s not too surprising that sense of worthlessness is considered a proximal trigger of suicide attempt, while issues like PTSD are assessed as distal – or more distant, background - factors.
Roughly 0.014% of people commit suicide worldwide. However, about 11 people attempt suicide for every 1 that is documented. Meaning about .14% of people are documented as suicidal or suicide attempting. And how many are undocumented? What we do know is major depression drives the behavior.
Suicide is a complex outcome of multiple, inter-related factors. The generally accepted model of suicide risk is the stress-diathesis risk factor model (Moscicki, 1997). Proximal, or trigger, risk factors such as depression or substance abuse are more closely related to SA and act as precipitants. Suicidal individuals differ from nonsuicidal individuals in distal risk factors such as traumatic experiences (Sarchiapone et al., 2007).
Suicide is a major public health problem worldwide, and approximately one million people died of suicide in the year 2000 (World Health Organization, 2013). An estimated 11 suicide attempts (SA) occur per every suicide death in the U.S. (Centers for Disease Control and Prevention, 2013). More than 90% of people who die by suicide have depression and mental disorders (Mościcki, 2001).
Major Depressive Disorder is implicated, especially due to its connections with other mental disorders, environmental conditions, and traumatic stress. And interestingly, while the experience of depression is unique between sufferers, worthlessness is one of the defining diagnostic criteria, suggesting it’s a stable characteristic. In fact, CBT for MDD focuses on negative beliefs, such as worthlessness, partially due to its correlation with suicide attempt.
But major depression doesn’t wander alone; it’s often hand in hand with PTSD. Trauma is also correlated with suicide attempt, with poor social experiences as one of the potential predisposing factors. With depression and low social support piggybacking on feelings of worthlessness, and bolstering the post-traumatic stress symptomology experience, we might have a perfect storm for suicidal ideation and attempt.
Many studies have investigated factors associated with SA in MDD patients, such as psychiatric comorbidities (Dumais et al., 2005; Stevens et al., 2013a), genetic factors (Lopez de Lara et al., 2007, 2006), melancholic features (Agargun et al., 2007; Jeon et al., 2013b), biomarkers (Kim and Myint, 2004), environmental factors (Jeon et al., 2013a), and traumatic experience (Jeon et al., 2009; Sarchiapone et al., 2007). MDD is a heterogeneous disorder which consists of nine symptoms of diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (DSM-5) (American Psychiatric Association, 2013). Feelings of worthlessness are prevalent depression symptoms in MDD patients and one of nine symptoms of diagnostic criteria for MDD.
Cognitive behavioral therapy (CBT) for MDD focuses on patients’ cognitions and schemata, such as seeing themselves as ‘worthless.’ Previous studies revealed that feelings of worthlessness may play an important role in the development of LSA
Traumatic experience is another important risk factor associated with LSA. From the study of Robins et al. (1957) which mentioned the interrelationships between social difficulties, diagnosis of depression and suicide attempt (Robins et al., 1957), individuals who had MDD with a history of trauma showed more depressed (Cook et al., 2001), atypical features (Withers et al., 2013), and more frequent LSA.
So these authors set out to better understand the interplay between these factors.
Methods:
In this study, researchers aimed to investigate the co-occurrence and correlation of major depression, trauma history, sense of worthlessness, and lifetime suicide attempts. The study was performed with a large pool of participants who underwent diagnostic interviews.
2.2. Measures
2.2.1. Assessment of DSM-IV disorders
DSM-IV diagnoses are based on the K-CIDI (World Health Organization, 1990), a fully structured diagnostic interview designed to make psychiatric diagnoses (American Psychiatric Association, 1994).
2.2.2. Assessment of traumas
The PTSD section of K-CIDI was used to evaluate lifetime traumatic events and DSM-IV PTSD criteria from A to F. For the beginning of the section, respondents were asked about traumatic events and experiences. They were handed cards on which were printed eleven kinds of traumas including ‘military combat’, ‘lifethreatening accidents’, ‘natural disaster’, ‘witnessed someone being killed or seriously injured’, ‘rape’, ‘sexual assault’, ‘badly beaten’, ‘threatened with a weapon’, ‘held captive, kidnapped, tortured and terrorism’, ‘any other extremely stressful or upsetting event’ and ‘learning about traumas to others’. If ‘any other extremely stressful or upsetting event’ and ‘learning about traumas to others’ were related to bereavement, chronic illness, business loss, or marital or family conflict, they were not regarded as traumatic events. If they checked any traumatic events, the interviewers continued the PTSD section.
2.2.3. Assessment of lifetime suicide attempt
Interviewers asked all subjects about suicidal ideation, plans, and attempts in a standard and consistent way using the following questions. The questions were ‘Have you ever seriously thought about committing suicide?’ for suicidal ideation, ‘Have you ever made a plan for committing suicide?’ for suicidal plan, and ‘Have you ever attempted suicide?’ for suicide attempt (Jeon et al., 2009; Lee et al., 2007). The participants responded to dichotomous questions with “YES” or “NO”, and then provided their age at first suicide attempt and number of suicide attempts. The questions showed strong validity between psychiatrists and interviewers of this study, as well as inter-rater and test-retest reliability with kappa values between 0.74 and 1.00 and 0.84 for MDD in a preliminary study for the KECA-R (Cho et al., 2005). Suicidal behavior was defined as suicidal ideation, plan, and attempt. After each question, the age of onset and last suicidal ideation, plan, and attempt was assessed through an open question form
And they found!
Discussion
There are two massive findings from this study.
First: sense of worthlessness predicts lifetime suicide attempt more intensely than any other depression symptoms. Actually, from a list of 20 options, worthlessness was the only symptom correlated with lifetime suicide attempt in this research. In another study, in a majorly depressed population, worthlessness has been shown to correspond with a 4-5 time increase of suicide attempt.
This study presents two important findings: first, feeling of worthlessness is more strongly associated with LSA than other depression symptoms in individuals with MDD. This study revealed significant differences in depression symptoms that were associated with LSA, and feelings of worthlessness were the only significant depression symptom associated with LSA among 20 depression symptoms. Although only a few published studies have addressed this issue, our findings are consistent with previous reports that feelings of worthlessness were the depressive symptom most strongly associated with LSA with 4- or 5-fold increase of SA risk in a community population with MDD in the USA.
On top of that rather definite finding, sense of worthlessness, trauma, and MDD promote lifetime suicide attempt in the following fashion: worthlessness predicts suicide attempt in individuals with significant trauma histories, and trauma history predicts suicide attempt for those with major depression who also had sense of worthlessness. They’re all related risk factors that predict each other!
The authors suggest this could be due to below-threshold post-traumatic stress. When an individual doesn’t meet the diagnostic qualifications for full-blown PTSD, feelings of worthlessness may still be present and linger. They might tip into major depression or strengthen already-active depression. Together, feelings of worthlessness, trauma history, and depression might result in suicide attempt.
Second, feelings of worthlessness are significantly associated with LSA only in those who have experienced serious trauma and vice versa in individuals with MDD. Feelings of worthlessness are a strong predictor for LSA in those who had experienced serious trauma, and serious trauma became a strong predictor for LSA in those who had feelings of worthlessness in individuals with MDD.
Individuals who had both history of PTSD and feelings of worthlessness showed higher odds ratios for LSA, compared with those who had no history of serious trauma. This study suggested that feelings of worthlessness may be long-term sequelae of serious trauma that did not fulfill full criteria of PTSD in individuals with MDD who had experienced serious trauma (Jeon et al., 2007). MDD with feelings of worthlessness is important to predict LSA in individuals who experienced serious trauma.
What kind of trauma is most likely to lead to suicide attempt? Military experience and significant beatings were both shown to predict lifetime suicide attempt. However, multiple traumas of any variety, when combined, have a similar effect.
Military combat and a bad beating were the most strongly associated with LSA in individuals with MDD. In contrast, multiple serious traumas had a similar odds ratio compared with any serious trauma.
And as they say:
Those findings tell us that there should be an interaction between interpersonal trauma and one of the few explicitly interpersonal symptoms of depression assessed in predicting SA. (worth-less-ness)
In conclusion, the findings of this study suggest a web of depression (ego forfeit), feelings of worthlessness compared to the rest of the population, trauma history of large unpersonal varieties or multiple interpersonal events, and eventual suicide attempt.
Worthlessness and trauma history with a side of MDD seem to be the strongest predictors, but so do worthlessness and major depression, with a trauma history that may or may not be enough to qualify for a PTSD diagnosis.
Meaning worthlessness may be the central promoting factor for suicidality; acting as the glue stringing together PTSD and depression, and worsening their cognitive and emotional effects, so they precipitate into one highly risky situation that may end lives.
And that is the major threat of estimating oneself worth-less.
TO BRING IT HOME
Here’s a little limitations excerpt for the nerds:
There are several limitations in the present study that should be considered when interpreting the findings. First, this is a cross-sectional survey, in which information about LSA, depressive symptom, and their diagnosis was based on retrospective reports. Therefore, a recall bias might have affected the accuracy of the data (Patten, 2003). The results showed association rather than causality between traumas and LSAs. Second, false negatives on the questionnaires could result in underestimation of the real prevalence of LSA or depression symptoms. Third, non-responsiveness to the interview may also have impacted these results, as it has been previously reported that nonrespondents have higher rates of mental disorders than respondents (de Graaf et al., 2000; Eaton et al., 1992). Fourth, the causes of feelings of worthlessness were not fully evaluated in this study. There needs to be a differentiation between MDD and other causes of feelings of worthlessness such as personality disorders and occupational and economic problems, and further comparison to LSA in MDD subjects.
Here, I want to point out that last sentence as it relates to societal messages of worthlessness which can pile on top of interpersonal lessons we may have picked up in childhood. Occupational and economic problems suggest or solidify worth deficits, and those need to be added as risk factors for suicide attempts.
And lastly, they say, to really pile-drive-home the role of worthlessness in self-harm and loss of life:
1 In conclusion, feelings of worthlessness are an important risk factor for LSA in individuals with MDD who have experienced serious trauma, with an odds ratio of 5.02 compared to those who have not.
2 Even though individuals with MDD who have experienced serious trauma do not fulfill the diagnostic criteria for PTSD, careful attention should be given to their history of trauma and risk for suicide if they have feelings of worthlessness.
3 If MDD subjects have a history of serious trauma, they should be evaluated for feelings of worthlessness.
and
4 Feelings of worthlessness and history of serious traumas should be evaluated and managed during treatment of MDD to help identify suicide risk.
It’s worthlessness assessment and unlearning, all the way down, to prevent suicidal attempt.
The good news being, this is one central factor and point for healing, in an otherwise multinodal and highly individual series of interrelated risks. Maybe we don’t need to deeply understand every person’s trauma history or depressive cognitions to save lives. We simply need to help people feel worth-equal.
And with that… thanks for being here.
There’s value in it, for everyone you know and don’t. You can’t know the depth of the impact you make, or to whom. You’re worth more than you believe.
And I’ll talk to you soon.