Surge in Suicide Prompts Call For Diagnostic Category

You are in a large department store late at night without your phone, unaware the store is closing. Suddenly you realize the place has emptied of customers and employees. You find an exit only to realize in a panic that the door is locked—in fact, all of the doors are locked—and you are alone.

And then the lights go out, pitch black.

That’s how one woman described her own state of mind in the period preceding a suicide attempt, a condition of “entrapment and frantic hopelessness,” says clinician and researcher Igor Galynker, M.D., Ph.D., director of the Mount Sinai Beth Israel Suicide Research Laboratory in the Department of Psychiatry at Icahn School of Medicine at Mount Sinai.

Galynker has sought to capture the acute mental state that characterizes the period when an individual may be most at risk for suicide. He has termed this state “suicide crisis syndrome” (SCS) and described features of the syndrome that might be spotted by psychiatrists, other physicians and health care professionals, or even family members and friends—even in the absence of self-reported “suicidal ideation.” Those features include, in addition to “entrapment and frantic helplessness,” affective disturbance, loss of cognitive control, social isolation, and hyperarousal (see story here).

Galynker would like to see the syndrome included as a diagnosis in DSM. “Nothing in medicine is 100%, and there is probably more than one pathway to suicide, but I believe the essential features of suicide crisis syndrome are present in the majority of suicides,” he told Psychiatric News.

He is among a handful of clinician researchers, including Maria A. Oquendo, M.D., Ph.D., past APA president and a director on the National Board of the American Foundation for Suicide Prevention, and Thomas Joyner, Ph.D., director of the Laboratory for the Study and Prevention of Suicide-Related Conditions and Behaviors at Florida State University, who are proposing the inclusion of “suicide-specific diagnoses” to APA’s DSM Steering Committee.

While Galynker’s SCS focuses on symptoms of the acute mental state preceding suicide, Oquendo has proposed a diagnosis of suicidal behavior disorder based on a history of suicidal attempts or behaviors. Joyner has proposed a third diagnosis, acute suicidal affective disturbance, roughly similar to SCS but including as a central component a sudden surge in suicidal intent occurring over the course of minutes, hours, or days.

Opponents of the idea cite stigma and liability concerns. But Galynker, Oquendo, and Joyner argue that in the face of an alarming rise in suicide rates, clinicians and health systems need to do a better job identifying patients at risk. They say specific diagnoses that capture a history of suicidal behavior and/or an acute pre-suicidal mental state can help identify and track patients in need of treatment specifically focused on suicidal thoughts and behaviors, as well as the comorbid psychiatric conditions associated with suicide. And they say that clinicians are already put in jeopardy of liability by having to rely on patients’ self-reports of suicidal ideation.

“Would we rely on patients with schizophrenia or bipolar disorder to diagnose themselves?” Galynker asked in comments to Psychiatric News. “We need a new approach to identifying people at risk that moves away from suicidal ideation and focuses more on acute mental states. An estimated 75% of suicides do not involve suicidal ideation until the immediate period preceding a suicide—or else it is missed or not reported during a clinical encounter.”