Authored by: Anna Stumps

Recent research published in Suicide and Life-Threatening Behavior by AD Stumps, N Bounoua, AE Sheehan, and N Sadeh, titled "Emotional reactivity and past self-injurious behavior moderate the association between trauma exposure and fearlessness about death," provides critical insights for clinicians working with trauma survivors.  

Clinical Takeaways:

• When assessing trauma survivors, include questions about current emotional reactivity and past self-injurious behaviors.
• Be aware that individuals with high emotional reactivity and a history of self-injury may be at elevated risk for fearlessness about death, which may further increase suicide risk.
• Consider using DBT skills in various populations, such as with trauma survivors who present with fearlessness about death.

The study uses Joiner’s Interpersonal Theory of Suicide (ITS) as an overarching framework to explore how trauma, emotional reactivity, and self-injurious behaviors contribute to acquired capability for suicide—particularly through fearlessness about death. Briefly, the ITS proposes that the the transition from thinking about suicide to engaging in suicidal behavior may be influenced by fearlessness about death. Specifically, the ITS theory suggests that engagement in suicidal behavior requires not only a suicidal desire, but also the capability to implement this desire, which has been conceptualized as a reduction in individuals’ innate fear about death or an increase in fearlessness about death (Van Orden et al., 2005, 2010). 

According to the ITS, frequent and repeated exposure to painful and provocative events (PPE), such as self-injurious behavior, physical abuse, and combat exposure, could contribute to the development of fearlessness about death. Briefly, this theory argues that repeated exposure to an emotional stimulus (e.g., threatening or physically harmful events) alters the natural stimulus response (e.g., fear) such that the stimulus no longer evokes the original response, but rather the opposite response emerges. In this case, repeated exposure to PPEs may alter individuals’ innate fear about death by eliciting an emotionally neutral (or even positive) response to death (i.e., fearlessness). Although there is research that supports the association between PPE and fearlessness about death, it is important to examine the relationship between multiple risk factors and fearlessness about death to more closely estimate the complexity of risk for suicide and the transition from ideation to action.  

The recently published study employed a cross-sectional study design to explore the complex relationships between suicide capability risk factors, including trauma exposure, emotional reactivity, and past self-injurious behavior, to better characterize their relationship with fearlessness about death.  

Overview of Methods

Study Sample

This study recruited a diverse sample of 273 community adults aged 18-55 (M/SD = 32.77/10.78) from Delaware, Maryland, and the greater Philadelphia area. Slightly less than half of the sample were female participants (49.1% vs. male 50.9%). Most participants identified as White/Caucasian (64.8%) and a substantial minority as Black/African American (26.7%). Past year household income ranged from $0 to >$100,000, with a median reported income of $50,000. The most common level of educational attainment reported was a high school diploma equivalent or less (53.9%), and slightly less than half of the sample (44.7%) reported prior justice-system involvement in their lifetime.

• Trauma Exposure. The Detailed Trauma Screen from the Structured Clinical Interview for DSM-5-Research Version (SCID-5-RV) Stressor Related Disorders module (First et al., 2015) was used to assess lifetime history of exposure to 7 different types of assaultive traumatic events at different developmental periods (early childhood, adolescence, adulthood). Assaultive trauma was operationalized as direct exposure to threatened or actual physical violence that was perpetrated by another individual, including physical abuse, being personally assaulted (i.e., robbed, mugged, shot, or physically injured), domestic violence, being threatened with a weapon, exposure to an active war zone, exposure to community violence, or sexual abuse/assault (Cisler et al., 2012; Sadeh et al., 2015). A majority of the sample (77.2%) reported a history of experiencing at least one assaultive trauma in their lifetime, and, on average, participants reported a history of multiple assaultive traumas.  
• Emotional Reactivity. Trait emotional reactivity was assessed using the Emotional Reactivity Scale (ERS; Nock et al., 2008). This construct captures different aspects of individuals’ emotional experience, including how intense their feelings are, how long they last, and how many different contexts evoke strong emotional responses.
• Self-Injurious Behavior. Lifetime engagement in self-injurious behavior, including nonsuicidal self-injury and suicide attempts, was assessed using two approaches because discrepancies in reporting across assessment modalities have been reported. Specifically, lifetime self-injurious behavior was assessed by combining responses on the Life History of Aggression (LHA; Coccaro et al., 1997) clinical interview and the Risky, Impulsive, and Self-destructive behavior Questionnaire (RISQ; Sadeh & Baskin-Sommers, 2017). This approach identified 78 participants (28.7%) who reported engaging in self-injurious behavior in their lifetime (NSSI or suicide attempt). Among those participants, 44 (16.1%) reported a history of at least one suicide attempt (24 of which also endorsed lifetime NSSI), and 34 (12.5%) endorsed lifetime NSSI with no history of a suicide attempt. Although NSSI and suicide attempts are distinct behaviors—differing in both intent and function—there are also overlapping features, such that both involve exposure to pain and were therefore considered together in the current study.  
• Fearlessness About Death. The Acquired Capability for Suicide Scale - Fearlessness About Death (ACSS; Ribeiro et al., 2014) was used to assess self-reported fearlessness about death (e.g., “The fact that I am going to die does not affect me”; “The prospect of my own death arouses anxiety in me”; “I am not at all afraid to die”).

Key Findings

While trauma exposure is a critical factor in mental health outcomes, this study provided evidence that trauma exposure alone may not directly relate to fearlessness about death. Rather, the study found that an individual’s degree of emotional reactivity and history of self-injurious behavior influences the relationship between trauma exposure and fearlessness about death.  

• Self-Injurious Behaviors: Current models of suicide risk have demonstrated that previous engagement of self-injurious behavior increases risk for future self-injurious behavior, which underscores the importance for clinicians to assess not only current, but also past engagement in self-injurious behavior. Study results provide additional information on how to consider self-injurious behavior within the context of trauma exposure by showing that the relationship between trauma exposure and fearlessness about death depended on whether or not individuals had previously engaged in self-injurious behavior. In other words, trauma exposure was related to greater fearlessness about death only for individuals who previously engaged in self-injurious behavior.  
• Emotional Reactivity: The study found that, among those who previously engaged in self-injurious behavior, individuals with heightened emotional reactivity show a stronger link between trauma exposure and fearlessness about death.  

Potential Clinical Implications

For clinicians, these findings underscore the importance of a nuanced approach when assessing and treating trauma survivors. Here are some practical applications:

When evaluating trauma survivors, consider not only the trauma history but also the individual's emotional reactivity and past self-injurious behaviors to provide a more comprehensive risk assessment for suicidal behavior.

Current evidence-based interventions that specifically address emotional reactivity, such as Dialectical Behavior Therapy (DBT), are particularly helpful for managing intense emotions and reduce self-injurious behaviors. When repeated trauma exposure cannot be minimized (i.e., career-related exposure, such as police officers, healthcare workers, and combat veterans, or unchangeable environmental circumstances), targeting emotional reactivity and engagement in self-injurious behaviors with DBT may reduce the impact of trauma exposure on the development fearlessness about death. Therefore, DBT may be a useful intervention for highly trauma exposed clients with reduced fear of death.  

Relatedly, integrating additional suicide prevention strategies that specifically target fearlessness about death may also be useful for comprehensively reducing suicide risk. One promising intervention is Franklin and colleagues (2016)’s mobile app called Therapeutic Evaluative Condition (TEC), which aims to increase disgust or aversion toward self-injurious behavior. Although research is needed to assess the relationship between TEC and fearlessness about death specifically, clinicians could integrate this aversion-based intervention into treatment to further reduce engagement in self-injurious behaviors, especially among clients who report high levels of fearlessness about death.  

Engaging Clinicians: Questions for Reflection

To further explore and apply these findings, consider the following questions:

• How can current trauma-focused therapies be adapted to better address emotional reactivity and past self-injurious behavior?
• What additional support systems can be integrated into clinical practice to enhance monitoring and support for high-risk individuals?
• How can we use this research to develop preventive measures that mitigate the risk of self-injury and suicide among trauma survivors?

We encourage you to share your thoughts and experiences in the comments below. Engaging in this dialogue helps us all better support those affected by trauma. 

Current Article Reference

• Stumps, A.D., Bounoua, N., Sheehan, A.E., & Sadeh, N. (2024). Emotional reactivity and past self‐injurious behavior moderate the association between trauma exposure and fearlessness about death. Suicide and Life‐Threatening Behavior.

References

• Cisler, J. M., Begle, A. M., Amstadter, A. B., Resnick, H. S., Danielson, C. K., Saunders, B. E., & Kilpatrick, D. G. (2012). Exposure to interpersonal violence and risk for PTSD, depression, delinquency, and binge drinking among adolescents: Data from the NSA-R. Journal of Traumatic Stress, 25(1), 33–40. https://doi.org/10.1002/jts.21672
• Coccaro, E. F., Berman, M. E., & Kavoussi, R. J. (1997). Assessment of life history of aggression: Development and psychometric characteristics. Psychiatry Research, 73(3), 147–157. https://doi.org/10.1016/S0165-1781(97)00119-4
• First, M. B., Williams, J. B. W., Karg, R. S., & Spitzer, R. L. (2015). Structured Clinical Interview for DSM-5-Research Version (SCID-5 for DSM-5, Research Version; SCID-5-RV). American Psychiatric Association.
• Franklin, J. C., Fox, K. R., Franklin, C. R., Kleiman, E. M., Ribeiro, J. D., Jaroszewski, A. C., ... & Nock, M. K. (2016). A brief mobile app reduces nonsuicidal and suicidal self-injury: Evidence from three randomized controlled trials. Journal of Consulting and Clinical Psychology, 84(6), 544–557. https://doi.org/10.1037/ccp0000093
• Joiner, T. E., Van Orden, K. A., Witte, T. K., & Rudd, M. D. (2005). The interpersonal theory of suicide: Guidance for working with suicidal clients. American Psychological Association.
• Joiner, T. E., Van Orden, K. A., Witte, T. K., Selby, E. A., Ribeiro, J. D., Lewis, R., & Rudd, M. D. (2010). The interpersonal theory of suicide: A framework for understanding suicide from a clinical perspective. American Psychological Association.
• Nock, M. K., Wedig, M. M., Holmberg, E. B., & Hooley, J. M. (2008). The Emotional Reactivity Scale: Development, evaluation, and relation to self-injurious thoughts and behaviors. Behavior Therapy, 39(2), 107–116. https://doi.org/10.1016/j.beth.2007.05.005
• Ribeiro, J. D., Witte, T. K., Van Orden, K. A., Selby, E. A., Gordon, K. H., Bender, T. W., & Joiner, T. E. (2014). Fearlessness about death: The psychometric properties and construct validity of the Acquired Capability for Suicide Scale–Fearlessness About Death. Psychological Assessment, 26(1), 115–126. https://doi.org/10.1037/a0034858
• Sadeh, N., Baskin-Sommers, A. (2017). Risky, impulsive, and self-destructive behavior questionnaire (RISQ): A validation study. Assessment, 24(7), 971–982. https://doi.org/10.1177/1073191115625805
• Sadeh, N., & Verona, E. (2015). Trauma exposure and fearlessness about death in male inmates: Interpersonal risk factors for suicide risk. Psychology of Violence, 5(4), 339–348. https://doi.org/10.1037/a0039651