The association between traumatic experiences and suicide attempt in patients treated at the Hospital de Pronto Socorro in Porto Alegre, Brazil

Objective: To analyze associations between attempted suicide and childhood trauma. Methods: A seven month comparative case-control study (28 subjects – patients with suicide attempt; 56 controls – patients without suicide attempt). The following instruments were used: Childhood Trauma Questionnaire (CTQ), Mini International Neuropsychiatric Interview (MINI), and Medical Outcomes Study (MOS). Results: The group with suicide attempt had significantly higher scores for some variables: emotional abuse (p < 0.001), physical abuse (p < 0.001), emotional neglect (p < 0.001), and physical neglect (p < 0.001). Conclusions: The results suggest that variables related to previous trauma may influence future suicide attempts. The adoption of preventive and therapeutic actions related to mistreatments during child development is a crucial factor in reduction of suicide risk.


Introduction
Suicide is a multi-causal problem for which, to date, no unified reference theory has been identified. It may be the result of a multifaceted interaction between biological, genetic, psychological, social, and cultural factors. Suicide behavior must be confronted as a public health problem. This is a broad task, because it involves training healthcare professionals for suicide risk (SR) detection as well as prevention and immediate treatment at the different levels of care. 1,2 Suicide is an ancient and cross-cultural theme and remains a public health problem worldwide. 3 One recent meta-analysis by Zatti et al. 4 identified childhood trauma as a modifiable risk factor for lifetime suicide attempts. In that study, sexual and emotional abuse and physical neglect (considered psychological traumas) were associated with suicide attempt (SA). Other studies have reported findings pointing in the same direction. 4 For example, Araújo 5 studied suicidal behavior and childhood trauma in a database of 71,429 volunteers.
The results illustrated an association between childhood emotional abuse and suicidal behavior and the author concluded that the most serious suicide attempts were associated with severe emotional abuse.
The results of a study conducted in Rio de Janeiro with patients who attempted suicide showed a significant difference between cases and controls, with less social support among the suicide attempt cases analyzed. 6 The present study is justified by the importance of investigating factors that can foment SR, such as traumatic experiences, mental illnesses, and loss of a significant relative. No data were found in the suicide attempt literature that directly relate recent losses with suicide attempt.
Considering the relevance of what has been outlined above, this study's main objective was to analyze the association between childhood trauma and suicide attempt in patients who needed hospital admission due to suicide attempts at the Hospital de Pronto Socorro

Childhood Trauma Questionnaire (CTQ)
The CTQ is an adapted and validated tool that has been widely used to investigate the occurrence of abusive situations during childhood. 8

Medical Outcomes Study (MOS)
This is a social support survey that evaluates the following dimensions: tangible support (provision of practical resources and material aid), affectionate support (physical demonstrations of love and affection), emotional support (capacity of the social network to satisfy individual needs related to emotional problems), informational support (counting on people who can offer guidance, information, and counsel), and positive social interaction (having people to relax and have fun with).
The MOS was developed by Sherbourne & Stewart,11 and translated and validated for Portuguese by Griep et al. [12][13][14] Answers to items "a" to "t" are distributed along a five-point Likert scale. 15

Mini International Neuropsychiatric Interview (MINI)
A short, standardized diagnostic interview (15-30 minutes). The Brazilian translation of version 5.0 for the DSM IV was used. 16

Sociodemographic questionnaire
Used to collect general information such as gender, age, education, income, marital status, and occupation.
As an additional item, the researcher also surveyed the medical team's clinical impression of the severity and lethality of each suicide attempt, case by case.
The lethality of each attempt was scaled by the doctors as: 1, mild (no clinical complications, no admission required); 2, moderate (with clinical complications, requiring hospital admission); or 3, serious (with critical complications, requiring Intensive Care Unit admission or special medical care).

Ethical aspects
All subjects were given the necessary clarifications. All participants were cared for by the HPS Psychology Service while in hospital, which also dealt with referrals for subsequent treatment as needed.

Statistical analysis
Attribute variables were expressed as absolute and relative frequencies. Quantitative variables were expressed as means and SD or medians and interquartile ranges, depending on the results of the Shapiro-Wilk test.
Groups were compared in terms of sociodemographic For the MOS questionnaire, odds ratios were calculated using conditional logistic regression.
Some variables consisted of one item with multiple answers. These variables were analyzed in descriptive form. Analyses were performed using SPSS v.18 software. The level of significance adopted was 0.05. Still with relation to the MOS results, Table 3 shows the results for the dimensions: The control group presented means equal to or above 4.4 in all dimensions. In contrast, all means were below 3.4   Results expressed as mean (95% confidence interval). p group = p value for the effect of the group; p gender = p value for the effect of gender; p interaction = p value for the effect of the group × gender interaction. protection against suicide risk and one additional point of tangible support is associated with 80% protection.

Participants
One additional point of affectionate support offers 69% protection against risk of suicide attempt; emotional support provides 55% (p < 0.001); informational support provides 71% (p < 0.001); and positive social interaction offers 65% protection. When combined, affectionate support and social interaction offer 70% protection (p < 0.001) with one additional point.
Family history data is shown in Table 4. Forty-three subjects responded to a parallel investigation about adverse events, memories, or significant dates and 65% (n = 28) exhibited proximity between the date of admission and anniversaries of these items, whether related to the patients themselves or to a close family member.   leading people to commit violent acts of self-harm. 18 In the suicide attempt sample collected at the HPS, 28% of the participants wrote some kind of suicide letter or sent messages through smartphone apps, i.e., they sought to express their unbearable psychic pain. In many cases, suicide attempt is founded on an absence of psychic resources capable of containing the psychic pain. 18 The results of the instrument for measuring social support for the sample as a whole showed that the mean number of relatives considered socially supportive was 3.4 (SD = 3.3), while the mean number of close friends was 1.9 (SD = 2.8). The sum of the mean numbers of relatives and close friends was higher for the control group (6.6) than for the case group (2.5) (p < 0.001).
In other words, patients in the control group had more social support and were more likely to be active and interactive in their social environments.
We sought to understand whether support from family or close friends would protect against suicide risk. As mentioned above, having one additional and emotional support; in other words, the higher the score for depressive disorder, the lower the scores for the MOS dimensions. 19 Certain crises, such as vital (aging) and circumstantial (unexpected events), for example, may lead to what Botega 20 calls existential collapse. This collapse generates anguish, helplessness, incapacity, burnout, and lack of prospects for solutions and may increase vulnerability to suicide, which begins to seem like a solution for the unbearable pain. 20 We investigated whether such existential collapse can be triggered by anniversaries or special dates that bring back memories or whether such dates can become overwhelming due to the individual having suffered intensely, such as feeling abandoned, helpless, and lacking prospects.
We analyzed the suicide attempt cases and obtained 11 positive answers for 11 anniversaries (including birthdays) and/or special dates: 54.5% (6 events In a longitudinal study that followed 183 youths who had suffered sexual abuse for 9 years, analysis showed that the risk of suicide was 13 times higher than that observed in the general population. 27 Studies of childhood abuse and suicidal behavior state that the risk of suicidal behavior increases according to the intensity of the abuse during childhood. 28,29 Forty-three participants answered a parallel investigation about events, memories, or birthdays/ anniversaries/important dates and 65% of them (n = 28) had an admission date near a birthday (the patient's own or that of a significant family member).
These data expose unconscious aspects involved in traffic accidents and bias in suicide attempts concealed in traffic accidents, and thus not considered suicide attempts, since the majority of people in the group were admitted due to the former. 30 Traffic accidents concern authorities throughout the world, given the number of people involved in fatal events of this kind. The victims might be indulging a desire for competition, speed, and living dangerously, poised between life and death. 31,32 The relationship between admission and commemorative dates suggests unconscious aspects to be analyzed. In short, we could suppose that presenting suicidal behavior or suicide risk represents sadistic fury against oneself. One of the limitations of this study is the number of participants, which prevents us from proposing generalizations.
Pompili conducted a bibliographic search on PubMed and PsycInfo for publications from 1955 to 2011 that reported evidence of a connection between drivers involved in traffic accidents and suicidal behavior. 33,34 Some scientists emphasize that the suicidal motivations or self-destructive impulses in traffic accidents are unconscious. 30,35 According to one estimate, by the year 2030, injuries caused by traffic accidents will be the fifth largest cause of death in the world. However, the phenomenon is most often reported as an accidental act in national statistics. 33 In the conclusions to a meta-analysis of longitudinal studies from the last decade, Zatti et al. 4 compared people who were exposed to traumatic events in childhood with the general population, showing that they are at increased risk of SA. Since the various forms of childhood trauma are preventable, there are strong reasons for governments to invest in programs, policies, and interventions to minimize childhood exposure to sources of severe adversity. 4

Conclusion
The results of this study show that situations of abuse or neglect provoke unbearable psychic pain, many times impairing reality test performance. Such