QJM Advance Access originally published online on April 21, 2007
QJM 2007 100(5):305-309; doi:10.1093/qjmed/hcm024
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Childhood abuse, adult alcohol use disorders and suicidal behaviour
From the Division of Neuroscience, Department of Psychiatry, Columbia University, and New York State Psychiatric Institute, New York, NY, USA
Address correspondence to Dr L. Sher, Division of Neuroscience, Department of Psychiatry, Columbia University, 1051 Riverside Drive, Suite 2917, Box 42, New York, NY 10032, USA. email: ls2003{at}columbia.edu
 |
Summary |
|---|
 Top Summary IntroductionAlcohol misuse as a...Alcohol abuse and suicideFamily history of alcoholismImplicationsReferences |
|---|
Childhood abuse is linked to a variety of maladaptive outcomes that can extend far into adulthood. Two of the most significant are alcohol use disorders and suicidal ideation/behaviour. This article explores the pathway from childhood abuse to suicidal behaviour through the development of alcohol use disorders, and examines the significance of a familial history of alcohol misuse in exacerbating suicidal behaviour in adults who were abused as children. It discusses the implications of this pathway, and describes areas of focus for those who work with child abuse victims and/or patients experiencing alcohol use disorders. Practitioners working with children or adolescents who have experienced or are experiencing abuse should take a preventative approach, identifying and treating those at risk for alcohol misuse and/or suicide. Practitioners working with adults who are already abusing alcohol and/or are suicidal should work with the adult to identify and examine life events such as abuse that may be responsible. By identifying factors that have led to the misuse of alcohol and/or suicidal ideation, adults can obtain appropriate psychotherapy and deal in a more productive and beneficial manner with the pain that underlies their self-destructive impulses.
|
Introduction |
|---|
|
TopSummaryIntroductionAlcohol misuse as a...Alcohol abuse and suicideFamily history of alcoholismImplicationsReferences |
|---|
In 2004, some 872 000 children in the US were estimated to be victims of child abuse or neglect.1 In the UK, there were 32 100 children on child protection registers in 2004,2 with 7% of all UK children experiencing serious physical abuse and 1% experiencing sexual abuse at the hands of their parents or care-takers during childhood.3 The impact of childhood abuse can be multi-faceted and extend far into adulthood.4–16 Consequences of early abuse may include both internalizing disorders (depression, anxiety, suicidal ideation) and externalizing problems (conduct disorders, aggression, alcohol or substance use, inappropriate or early sexual activity, suicidal behaviour).4–11
The trauma of childhood physical and sexual abuse has repeatedly been reported as linked with both suicidal behaviour and alcohol use disorders.12–16 Adult women with a history of abuse are at an increased risk for developing depression, anxiety, substance abuse and suicidality,12 and adult women in treatment for alcohol abuse are more likely than those in the general population to report childhood sexual abuse and physical violence.13 Sexual abuse has also been implicated in the development of suicidal thoughts in adults: empirical studies demonstrate greater suicidal ideation and suicidal behaviour in both clinical and community populations of adults who report childhood sexual and/or physical abuse than in comparison groups who do not.14 For example, Briere15 found that 51% of sexual abuse victims (vs. 34% of non-abused participants) demonstrated a history of suicide attempts, and that 31% of victims (vs. 19% of non-abused individuals) reported self-harm ideation. Gutierrez16 found that college-aged women who had been abused as children claimed higher levels of suicidal ideation and felt less repulsion for death and more repulsion for life. There appears to be a correlation between the experience of abuse in childhood and the presence of suicidal thoughts and behaviour in adulthood. This article aims to explain the path from childhood abuse toward suicidal behaviour through the development of alcohol use disorders.
|
Alcohol misuse as a consequence of childhood abuse |
|---|
|
TopSummaryIntroductionAlcohol misuse as a...Alcohol abuse and suicideFamily history of alcoholismImplicationsReferences |
|---|
Victims of abuse may begin abusing alcohol for a variety of reasons. Alcohol and substance use disorders are a common coping strategy adopted by adults who were abused as children in attempting to adapt and distance themselves from the painful traumas they have experienced.17 Victims may turn to alcohol in an attempt to cope with the reactions they have towards their abuse. Alcohol may be used as a way to reduce feelings of isolation and loneliness, as a method of self-medication in an attempt to gain control over what the victims have experienced, as a way to improve self-esteem, or as a means with which to gain relief from the persistent memories of abuse.19,20 Alcohol misuse can be a form of self-destructive behaviour that arises from poor self-concept, self-blame, and feelings of worthlessness.6 It can provide an emotional and psychological escape from an abusive environment by creating an effect of stress reduction and the same feelings of disassociation that may have been used to deal with the horror of abuse.5,7,8 Adults who have experienced abuse during their childhood appear to develop alcohol use disorders as they search for avenues to turn to in order to cope with the experiences through which they suffered.
|
Alcohol abuse and suicide |
|---|
|
TopSummaryIntroductionAlcohol misuse as a...Alcohol abuse and suicideFamily history of alcoholismImplicationsReferences |
|---|
Alcohol can also be responsible for creating a disinhibiting effect, allowing for the breakthrough of self-destructive impulses into actual behaviour.21 The trauma of child victimization is often associated with the self-destructive impulse of suicidality that emerges from isolation, loneliness, depression and a loss of self-esteem.4–11 Great importance has been ascribed to alcohol misuse as exacerbating and eliciting suicidality, and to it being chronic suicide in itself.22 One hundred and fifty years ago, Charles Wilson explained:
There are two forms under which the tendency to suicide exhibits itself in the confirmed drunkard, and it is of considerable practical importance that these should be distinguished. In the one form, the act assumes the appearance of cool deliberation, has frequently been long contemplated, and is approached with every precaution to prevent detection, and to secure its completion. Under the second form the act itself is without premeditation, in the strict sense of the term, and is a direct consequence of those more violent states of disorder of the intellect, for which he is no longer responsible than they are the results of his excesses.
He also stated:
... should [the alcoholic] lift his hands against his life, armed with an instrument more promptly fatal, it is by a kind of double-suicide that the last act is perpetrated. The more gradual self-destruction, which simulates disease is crowned by the rapid catastrophe which kills by violence. It is the character of the act which is changed, but not its essence.18
Almost a century later, in 1938, Karl Menniger stated that the same wishes support alcoholism and suicide: ‘the wish to kill, the wish to be killed, and the wish to die.’22 Suicidal ideation may be present in many individuals who have experienced childhood abuse, but it is the alcohol misuse that is frequently exhibited in abused individuals that often serves as the facilitator of the suicidal act. Crombie et al.23 reported that 45% of the completed suicide cases they studied consumed alcohol prior to their deaths and 19% were drunk at the time of suicide. It is possible that the effects of drinking or being intoxicated may lead to increased and intensified suicidal ideations or behaviours.
Alcohol misuse increases the number of unplanned suicide attempts among those who already have suicidal ideation,24 and alcohol use is predictive of subsequent suicide attempts.24 One out of every twenty active alcoholics who are hospitalized with depression die by suicide within two years without remission from alcoholism,25 overall there is an increased risk of suicidal behavior in individuals who have abused alcohol.26 Additionally, when alcoholics attempt suicide they tend to use more lethal methods than non-alcoholics.27 determined that it is only when a diagnosis of alcohol dependence is present that suicidal ideation and lethality of the suicide attempt are correlated. While suicidal intent may be chronically present in many people who were victims of child abuse, the misuse of alcohol appears to make suicidal action more likely.
|
Family history of alcoholism |
|---|
|
TopSummaryIntroductionAlcohol misuse as a...Alcohol abuse and suicideFamily history of alcoholismImplicationsReferences |
|---|
A family history of alcoholism is associated with both alcohol misuse and suicidal behaviour,28–37 Depressed individuals with a family history of alcoholism have a significantly higher prevalence of reported child physical and sexual abuse, more suicide attempts, and a greater intent to die when making their most lethal suicide attempt than individuals without a family history of alcoholism.28 Genetic and environmental factors both contribute to these outcomes; no person is merely a consequence of only their genetics or only their environment; they select specific environments to operate in based on their genetic propensities.28 Genetically, sons of alcoholic parents exhibit deficient serotonin functioning and tryptophan depletion.29,30 Tryptophan depletion impaired performance in a behavioural inhibition task in subjects with a positive family history, compared to subjects without alcoholic relatives.30 Other biological differences have also been found as a function of a family history of alcoholism.30–36 Subjects with alcoholism who reported a positive family history of problem drinking had larger startle blink amplitudes and smaller auditory and visual event-related brain potentials than did subjects with alcoholism who reported a negative family history.33 Lower amplitude of event-related brain potentials might reflect an aspect of neurophysiological inhibition that underlies the behavioural disinhibition that is associated with alcoholism risk.36 The sons of alcoholics have lower cortisol and prolactin levels after drinking,31,32 and compared to non-alcoholic men with a negative family history of alcohol misuse, non-alcoholic men with a positive family history had greater levels of the stimulatory G-protein Gs alpha in erythrocyte and lymphocyte membranes.34 In another study, ethanol increased the plasma level of beta-endorphin-related peptides in subjects from families with a history of alcoholism, but not in subjects from families without no such history.35 Suicidal behaviour may result from a genetically-based reduction of behavioural inhibition in those who grow up with familial alcohol problems.
Environmentally, the microenvironment between the developing infant and alcoholic parent is often characterized by harsh physical punishment and family violence, and is predictive of future problems.28 Additionally, family alcoholism and the experience of child abuse is a risk factor for the development of alcoholism and major depression. This alcohol misuse increases the risk of suicide in individuals with major depression.28,37 Experiencing ongoing child abuse can cause depressive feelings that may lead to suicidal impulses. These impulses may be acted on by individuals as a consequence of the development of alcohol use disorders. A family history of alcoholism appears to play a genetic and environmental role in heightening and intensifying the suicidal ideation that often emerges in adults who were abused as children.
|
Implications |
|---|
|
TopSummaryIntroductionAlcohol misuse as a...Alcohol abuse and suicideFamily history of alcoholismImplicationsReferences |
|---|
Given the relationship between alcohol dependence and psychiatric illness, early diagnosis of alcohol misuse is important. All psychiatric patients should be screened for alcohol use disorders as an initial part of their risk assessment.38 Common psychiatric disorders that are comorbid with alcohol-misusing patients who report childhood abuse include major depression, post-traumatic stress disorder (PTSD), generalized anxiety, social phobia, agoraphobia and suicide attempts.39 Additionally, because alcohol is often used as a coping mechanism by abuse victims, it is crucial for abuse victims to be identified when evaluating and treating patients who misuse alcohol, to prevent or reduce any impending onset of alcohol abuse or dependence.39 Given the comorbidity between alcohol misuse and suicide, it is also essential that all patients with alcohol use disorders be screened for suicidality. Patients with an early onset of heavy drinking have an increased rate of suicide attempts,40 and those who start abusing alcohol in their teen years are four times more likely to attempt suicide than those who start abusing alcohol later in life.41
Treatment options for abuse victims who display alcoholism and suicidality can vary. For those who suffer from comorbid depression, it is helpful to first focus on abstinence and then treat the depression. Individuals depressed after one week of abstinence have superior outcomes with antidepressant treatment than those without a period of abstinence.38 Higher service intensity in acute treatment centres has also been associated with better substance and psychiatric outcomes, both at discharge and at 12 months. These higher-intensity programs are able to provide strategies for substance abuse using psychiatric, counselling, rehabilitation and recreational services.38 However, not all suicidal patients have the benefit of seeing a mental health provider. Emergency department staff often have to deal with patients who present acutely with alcohol use disorders, psychiatric disorders and suicidality. It is essential that these staff have the knowledge and skills to provide the immediate help patients need before they can see a mental health practitioner.38 Lastly, many adults who are victims of dysfunctional parenting have grown up with feelings of isolation, negative self-concept, and a diminished ability to establish meaningful relationships.39 Support systems are needed to assist in the development of healthy adult functioning in such victims. Adults who do suffer from alcohol abuse or dependence need to be given the opportunity to explore any abuse they may have suffered though as a child. Through giving voice to their painful experiences, it is hoped that the suicidal impulses that stem from their pain can be exposed and dealt with in a constructive and therapeutic manner that will reduce their need for a suicide attempt.
|
References |
|---|
|
TopSummaryIntroductionAlcohol misuse as a...Alcohol abuse and suicideFamily history of alcoholismImplicationsReferences |
|---|
1. US Department of Health and Human Services Child Maltreatment. (2004) [http://www.acf.hhs.gov/programs/cb/pubs/cm04/cm04.pdf] Accessed October 2006.
2. Department for Education and Skills. Statistics of Education: Referrals, Assessments and Children and Young People on Child Protection Registers: Year Ending 31 March 2004. [http://www.dfes.gov.uk/rsgateway/DB/VOL/v000553/referrals_with_cover_final.pdf] Accessed October 2006.
3. Cawson P, Wattam C, Brooker S, Kelly G. (2000) Child maltreatment in the United Kingdom: a study of the prevalence of child abuse and neglectLondon NSPCC.
4. Paolucci EO, Genuis ML, Violato C. (2001) A meta-analysis of the published research on the effects of child sexual abuse. J Psychol 135 17–36.[ISI][Medline]
5. Neumark-Sztainer D, Story M, French SA, Resnick MD. (1997) Psychosocial correlates of health compromising behaviors among adolescents. Health Educ Res 12 37–52.
6. Lindberg F and Distad LS. (1985) Survival responses to incest: Adolescents in crisis. Child Abuse Negl 9 521–6.[CrossRef][ISI][Medline]
7. Downs WR, Miller BA, Testa M. ( November 1991) The impact of childhood victimization experiences on women's drug use. Paper presented to the annual meeting of the American Society of Criminology, San Francisco, CA.
8. Harrison PA, Hoffman NG, Edwall GE. (1989) Differential drug use patterns among sexually abused adolescent girls in treatment for chemical dependency. Int J Addict 24 499–514.[ISI][Medline]
9. Cavaiola A and Schiff M. (1989) Self-esteem in abused chemically dependent children. Child Abuse Negl 13 327–34.[CrossRef][ISI][Medline]
10. Dembo R, Williams L, La Voie L, Schmeidler J, Kern, J, Getreu A, Barry E, Genung L. (1990) Wish E. A longitudinal study of the relationship among alcohol use, marijuana/hashish use, cocaine use, and emotional/psychological functioning problems in a cohort of high risk youths. Int J Addict 25 1341–82.[ISI][Medline]
11. Testa M, Miller BA, Downs WR, Panek D. (1992) The moderating impact of social support following childhood sexual abuse. Violence Vict 7 173–86.[Medline]
12. Briere J and Runtz M. (1986) Suicidal thoughts and behaviours in former sexual abuse victims. Can J Behavioural Science 18 413–23.[CrossRef]
13. Miller B, Downs W, Testa M. (1993) Interrelationships between victimization experiences and women's alcohol use. J Stud Alcohol 11 109–17.
14. Santa Mina E and Gallop R. (1998) Childhood sexual and physical abuse and adult self-harm and suicidal behaviour: A literature review. Can J Psychiatry 43 793–800.[ISI][Medline]
15. Briere J. (1984) The effects of childhood sexual abuse on later psychological functioning: defining a post-sexual abuse syndrome. In:. The Third National Conference on Sexual Victimization of Children Washington (DC).
16. Gutierrez PM, Thakkar RR, Kuczen C. (2000) Rxploration of the relationship between physical and/or sexual abuse, attitudes about life and deat, and suicidal ideation in young women. Death Studies 24 675–88.[CrossRef][ISI][Medline]
17. Widom CS, Weiler BL, Cottler LB. (1999) Childhood victimization and drug abuse: A comparision of prospective and retrospective findings. J Cons Clin Psychol 67 867–80.[CrossRef][ISI][Medline]
18. Wilson C. (1855) The Pathology of DrunkennessBlack Edinburgh.
19. Widom C, Ireland T, Glynn P. (1995) Alcohol abuse in abuse and neglected children followed-up: Are they at increased risk? J Stud on Alcohol 56 207–17.
20. Epstein J, Saunders B, Kilpatrick D, Resnick H. (1998) PTSD as a mediator between childhood rape and alcohol use in adult women. Child Abuse Negl 22 223–34.[CrossRef][ISI][Medline]
21. Borges G and Rosovsky H. (1996) Suicide attempts and alcohol consumption in an emergency room sample. J Studies Alc 7 543–8.
22. Menninger KA. (1938) Man against himselfNew York Harcourt Brace.
23. Crombie IK, Pounder DJ, Dick PH. (1998) Who takes alcohol prior to suicide? J Clin Forensic Med 5 65–8.[CrossRef][Medline]
24. Gossop M. (2005) Alcohol in suicide attempts and completions. Psychiatric Annals 35 513–19.[ISI]
25. Hasin DS, Endicott JN, Keller MB. (1989) RDC alcoholism in patients with major affective syndromes: Two-year course. Am J Psychiatry 7 318–23.
26. Combs-Orne T, Taylor JR, Scott EB, Holmes SJ. (1983) Violent deaths among alcoholics: A descriptive study. J Stud Alcohol 44 938–49.[ISI][Medline]
27. Nielsen AS, Stenager E, Brahe UB. (1993) Attempted suicidal intent and alcohol. Crisis 14 32–8.[Medline]
28. Sher L, Oquendo MA, Conasion AH, Brent DA, Grunebaum MH, Zalsoma G, Burke AK, Mann JJ. (2005) Clinical features of depressed patients with or without a family history of alcoholism. Acta Psychiatr Scand 112 266–71.[CrossRef][ISI][Medline]
29. Rausch JL, Monteiro MG, Schuckit MA. (1991) Platelet serotonin uptake in men with family histories of alcoholism. Neuropsychopharmacology 4 83–6.[ISI][Medline]
30. Crean J, Richards JB, de Wit H. (2002) Effect of tryptophan depletion on impulsive behavior in men with or without a family history of alcoholism. Behav Brain Res 136 349–57.[CrossRef][ISI][Medline]
31. Schuckit MA, Gold E, Risch C. (1987) Plasma cortisol levels following ethanol in sons of alcoholics and controls. Arch Gen Psychiatry 44 942–5.[Abstract]
32. Schuckit MA, Gold E, Risch C. (1987) Serum prolactin levels in sons of alcoholics and control subjects. Am J Psychiatry 144 854–9.
33. Pfefferbaum A, Ford JM, White PM, Mathalon D. (1991) Event-related potentials in alcoholic men: P3 amplitude reflects family history but not alcohol consumption. Alcohol Clin Exp Res 15 839–50.[CrossRef][ISI][Medline]
34. Wand GS, Waltman C, Martin CS, McCaul ME, Levine MA, Wolfgang D. (1994) Differential expression of guanosine triphosphate binding proteins in men at high and low risk for the future development of alcoholism. J Clin Invest 94 1004–11.[ISI][Medline]
35. Gianoulakis C, Krishnan B, Thavundayil J. (1996) Enhanced sensitivity of pituitary beta-endorphin to ethanol in subjects at high risk of alcoholism. Arch Gen Psychiatry 53 250–7.[Abstract]
36. McGue M, Iacono WG, Legrand LN, Malone S, Elkins I. (2001) Origins and consequences of age at first drink. I. Associations with substance-use disorders, disinhibitory behavior and psychopathology, and P3 amplitude. Alcohol Clin Exp Res 25 1156–65.[CrossRef][ISI][Medline]
37. Widom CS and Hiller-Strurmhofel S. (2005) Alcohol abuse as a risk factor for and consequence of child abuse. Alcohol Res Health 25 52–7.
38. Hesselbrock M, Hesselbrock V, Syzmanski K, Weidenman M. (1988) Suicide attempts and alcoholism. J Stud Alcohol 49 436–42.[ISI][Medline]
39. Buydens-Branchey L, Branchey M, Noumair D. (1989) Age of alcoholism onset. I. Relationship to psychopathology. Arch Gen Psychiatry 46 225–30.[Abstract]
40. Baigent MF. (2005) Understanding alcohol misuse and comorbid psychiatric disorders. Curr Opin Psychiatry 18 223–8.[ISI][Medline]
41. Langeland W, Draijer N, vanden Brink W. (2004) Psychiatric comorbidity in treatment-seeking alcoholics: The role of childhood trauma and perceived parental dysfunction. Alcohol Clin Exp Res 28 441–7.[CrossRef][ISI][Medline]
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||