Researchers and clinicians have recently advocated for the inclusion of a suicide-specific diagnosable condition in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5),1 the current gold standard classification system for mental disorders.2–8 Until recently, suicidal thoughts and behaviors were included solely as symptoms of other psychiatric conditions, including major depressive disorder and borderline personality disorder, as opposed to being a diagnostic category of their own. In response, suicidal behavior disorder, defined by suicidal behavior occurring in the preceding 24 months, was included as a condition for further study in an appendix of DSM-5.1 Although knowledge of recent suicidal behavior is clinically informative9 and is reflected as such in leading frameworks of suicide risk assessment,10,11 past suicide attempts provide only minimal incremental prediction of future attempts,9 with little to no short-term predictive value. Indeed, suicidal behavior disorder relies almost entirely on a single risk factor (ie, past suicide attempts), as opposed to more clinically informative warning signs for imminent suicidal behavior.12
Recent research suggests that a transition from suicidal thoughts to behaviors may be preceded by a distinct pre-suicidal state. For instance, some researchers have found that suicidal people often experience increased anxiety, panic, agitation, or “psychic pain” before engaging in suicidal behavior.13,14 Others report an acute, high-intensity state of negative affect that serves as a trigger for suicidal behavior.15–18
Accordingly, we contend that a suicide-specific diagnosable condition should parsimoniously reflect acuity and characterize not only if, but also when, a person will engage in suicidal behavior. Two potential clinical syndromes have been proposed to fill this diagnostic void—acute suicidal affective disturbance (ASAD)4,5 and suicide crisis syndrome (SCS).19–22 In the following text we (1) discuss the phenomenology and existing empirical evidence for each of these two conditions, including two illustrative cases; (2) compare and contrast the features of ASAD and SCS; and (3) provide an overview of a number of future research directions needed to validate these potential diagnostic entities.
Acute Suicidal Affective Disturbance
Phenomenology and Empirical Evidence
ASAD combines empirically supported psychological states and theory-driven predictors of suicide into a parsimonious characterization of acute, drastic spikes in suicidality. Importantly, ASAD is posited to be time-limited; the term “disturbance” was chosen over “disorder” to further reflect the acute nature of the condition. The proposed diagnostic criteria for ASAD include the following:4,5
a geometric increase in suicidal intent over the course of hours or days, as opposed to weeks or months;
marked social alienation (eg, severe social withdrawal, disgust with others, perceived burdensomeness) and/or self-alienation (eg, self-hatred, psychological turmoil/pain);
perceptions that one's suicidal intent and social/self-alienation are hopelessly intractable; and
two or more manifestations of overarousal (ie, agitation, marked irritability, insomnia, nightmares).
Preliminary evidence supports a unidimensional factor structure for ASAD through the use of both proxy measures4,8,23 and standardized measures that specifically assess ASAD symptoms5 (also, M.L.R., unpublished data, 2017). Furthermore, ASAD has demonstrated convergent and discriminant validity with other psychiatric disorders and suicide-related symptoms across samples of undergraduate students,5 psychiatric outpatients,23 and psychiatric inpatients.4
A 23-year-old engineering major with a history of anxiety and depression presented to the emergency department because she felt suicidal. She had recently moved back home with her mother after graduating from college. She was struggling to find a job, and 1 week prior to presenting her long-term boyfriend had ended their relationship. In the emergency department, she told the doctor that she was disgusted with herself for continuing to send text messages to the ex-boyfriend and felt disconnected from others. She told her doctor that she had recently developed a strong intention of attempting suicide because the people in her life would be better off without her. The prior night, her psychological tension prevented her from being able to sleep. She had not shared her thoughts with anyone for fear of them perceiving her as even more of a burden. “I thought of going to visit a friend, but then I thought she would just tell me to snap out of it, so I did not go. Nobody cares. Nobody ever will.”
In this example, the patient experienced an exponential increase in suicidal intent (criterion A) after romantic rejection that led to thwarted belongingness, and perceived burdensomeness with regard to her mother (criterion B). She also experienced overarousal as manifested by insomnia and psychological tension/agitation (criterion D) and hopelessness that her suicidality and thwarted interpersonal needs would ever improve (criterion C). Together, these symptoms meet criteria for ASAD.
Suicide Crisis Syndrome
Phenomenology and Empirical Evidence
SCS comprises cognitive and affective symptoms in response to a real or perceived threat. This threat is an unacceptable life situation seen as intolerable and inescapable (typical examples are diagnosis with a terminal illness, shame-inducing loss of or failure at work, or loss of/rejection by a romantic partner).
The core feature of SCS (criterion A) is a persistent or recurring feeling of entrapment—an urgency to escape or avoid an unacceptable life situation that is perceived to be impossible to escape, avoid, or endure.20,22 Death may appear as the only escape; thus, persistent thoughts of death or suicide may be common.13,24 Explicit suicidal ideation need not be (although may often be) present, however.
Criterion B comprises affective, cognitive, and behavioral changes associated with the criterion A experience of entrapment19,22 (Table 1).
Criterion B for Suicide Crisis Syndrome
Within SCS, affective disturbance supports the perception of a need to escape, loss of cognitive control supports the perception of impossibility of escape and impairs problem-solving capacity, and hyperarousal motivates action to escape. To fulfill criterion B, at least one item from each component (ie, a, b, and c) must be present simultaneously or in close temporal proximity (ie, same day), either persistently or recurrently. Symptoms may last minutes to days and present with a progressively increasing course, a rapidly relapsing-remitting course, or a mixture of the two. Component d (social withdrawal) may also be present and increases risk but is not considered intrinsic to SCS. Preliminary evidence indicates the syndromic coherence of these proposed criteria, their associations with suicidal ideation, and their incremental predictive validity for short-term suicidal behavior.19–22
A 32-year-old lawyer with a history of bipolar II disorder, scheduled a therapy appointment because she was frightened by her thoughts. She was recently asked to resign from her firm because she was not perceived to be a team player and was not getting along with senior partners. She told her therapist that her career was destroyed and her life was in shambles. She saw no ability to erase the disgrace of being let go and felt that she had reached a dead end. She felt waves of anxiety and despair that came without warning and worsened at night. She could not sleep and she could not stop thinking about her “mistakes that ruined [her] life”—thoughts that kept “running around in circles.” “Somehow I managed to sleep yesterday, but I woke up feeling worse. I need to do something soon...” She denied wanting to kill herself but admitted that she spent half an hour the night before “just staring at all [her] pills” because it would be nice “just to escape from this nightmare.”
Beatrice's perception of no future and no good options is a manifestation of entrapment in an unbearable life situation with escape perceived as impossible (criterion A). Despite staring at her pills, she does not have explicit suicidal intent, which is not required for SCS. Beatrice also has all three required criterion B components: (1) affective disturbance, manifested by unbearable pain that comes in waves, (2) loss of cognitive control (ruminative flooding), and (3) hyperarousal exemplified by insomnia and restlessness.
Comparison of ASAD and SCS
A number of similarities exist across the proposed ASAD and SCS diagnostic criteria. Both disturbances reflect acute, rapidly increasing symptoms that precede suicidal behavior. Further, the presence of specific symptom domains, including overarousal, hopelessness, and social withdrawal, are comparable across both conditions. However, there are some differences. Most importantly, ASAD is characterized by escalating, conscious suicidality, with the cardinal symptom of drastically increasing suicidal intent, and accompanying symptoms of social withdrawal, hopelessness, and overarousal. On the other hand, the core symptom of SCS is entrapment. Indeed, SCS does not require any conscious suicidal intent. Loss of cognitive control in SCS represents a breakdown in executive function that leads to impaired problem-solving and increased susceptibility to selecting suicide as a solution, whereas explicit suicidal intent is a core criterion of ASAD. Further, whereas ASAD is characterized by a steep exponential escalation of its core symptoms, SCS describes interconnected affective, cognitive, and arousal symptoms that may escalate with a gradual, rapid, or fluctuating course.
Moreover, although symptom domains are present in both the proposed ASAD and SCS criteria, their importance and clinical presentation differ. For instance, cognitive and behavioral social withdrawal is a core feature of ASAD, but not intrinsic to the presence of SCS. Similarly, hopelessness is present in both ASAD and SCS; however, as a part of SCS, hopelessness is subsumed by the concept of entrapment, which entails also an intense need to escape, whereas as a part of ASAD, hopelessness about the possibility of one's suicidal and interpersonal symptoms improving is paramount, independent of experienced need to escape. Finally, overarousal symptoms are comparable across both disturbances, although nightmares are included as part of ASAD and hypervigilance is emphasized as part of SCS.
Future Research Directions
Before either ASAD or SCS can be validated as a clinically useful diagnostic entity, a number of future research directions should be taken. In a classic article, Robins and Guze25 delineate a set of five criteria for achieving diagnostic validity in psychiatric disorders: (1) clinical description, (2) laboratory studies, (3) delimitation from other disorders, (4) follow-up studies, and (5) family studies. Most studies of ASAD and SCS to date can currently be considered clinical description, laboratory, and delimitation from other disorder studies, although the most recent SCS study demonstrated short-term predictive validity in a high-risk cohort.22 Thus, studies that examine ASAD and/or SCS prospectively, particularly with the use of short-term designs in large cohorts, and that examine these syndromes in families, would be beneficial to further establishing the validity and clinical utility of ASAD and SCS.
ASAD and SCS also need to be compared empirically to examine which set of criteria demonstrates greater reliability and validity as a suicide-specific entity. No study to date has examined ASAD and SCS within a single sample; as such, this represents an important avenue for future research. Certain aspects of ASAD and SCS could be integrated into a single disturbance; for instance, the SCS criteria of ruminative flooding and integrated affective, cognitive, and arousal symptoms may precede drastic spikes in suicidal intent. Indeed, preliminary evidence suggests that frequency of suicide-specific rumination is associated with ASAD symptoms,26 suggesting that a ruminative cognitive style, whether specifically about one's suicidal thoughts or ruminative flooding more generally, may be an important factor in short-term suicide risk. Further, although ASAD delineates a geometrically increasing course of symptoms, a potentially fluctuating course, as outlined by SCS, may better characterize suicidal crises. Finally, greater attention to specific symptoms (eg, social alienation/withdrawal) may be more reflective of acute suicidal spikes.
Finally, all research to date on ASAD and SCS has focused on fairly homogeneous adult populations. Because suicide is the second leading cause of death for people between ages 10 and 24 years,27 a vital direction for future research is to identify whether either ASAD or SCS provides a useful framework for making predictions about the severity of the acute suicidal state in youth and adolescent populations. We conjecture that, much like suicidal behavior itself, ASAD and SCS occur, but are relatively rare, in children and increase in prevalence throughout adolescence and into adulthood. Moreover, there may be cultural factors that result in variation in symptom manifestation across various racial/ethnic groups that should be examined in future research.
Two potential solutions to a gap in the current diagnostic classification system have been proposed to characterize imminent suicide risk: ASAD and SCS. Both time-related disturbances propose useful diagnostic algorithms to help clinicians more accurately identify patients at high risk for imminent suicidal behavior. Preliminary evidence supports the factorial structure and convergent, discriminant, and predictive validity4,5,19–22 of ASAD and SCS; however, future research is needed to determine which disturbance or set of symptoms best represents acute risk in the hours or days preceding suicidal behavior, as well as how symptoms might vary in their temporal dynamics. Such an effort to integrate and weight this information may allow clinicians to more adequately probe the severity of the acute suicidal state. Ultimately, should either ASAD or SCS be demonstrated as clinically useful in assessing and managing acute suicide risk, there is great potential for increased prevention of suicide.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Publishing; 2013.
- Oquendo MA, Baca-García E, Mann JJ, Giner J. Issues for DSM-V: suicidal behavior as a separate diagnosis on a separate axis. Am J Psychiatry. 2008;165(11):1383–1384. doi: http://dx.doi.org.proxy.lib.fsu.edu/10.1176/appi.ajp.2008.08020281. doi:10.1176/appi.ajp.2008.08020281 [CrossRef]
- Oquendo MA, Baca-Garcia E. Suicidal behavior disorder as a diagnostic entity in the DSM-5 classification system: advantages outweigh limitations. World Psychiatry. 2014;13(2):128–130. doi: . doi:10.1002/wps.20116 [CrossRef]
- Stanley IH, Rufino KA, Rogers ML, Ellis TE, Joiner TE. Acute Suicidal Affective Disturbance: a confirmatory factor analysis among psychiatric inpatients. J Psychiatr Res. 2016;80:97–104. doi: . doi:10.1016/j.jpsychires.2016.06.012 [CrossRef]
- Tucker RP, Michaels MS, Rogers ML, Wingate LR, Joiner TE. Construct validity of a proposed new diagnostic entity: Acute Suicidal Affective Disturbance (ASAD). J Affect Disord. 2016;189:365–378. doi: . doi:10.1016/j.jad.2015.07.049 [CrossRef]
- Van Orden KA, Witte TK, Holm-Denoma J, Gordon KH, Joiner TE. Suicidal behavior on Axis VI: clinical data supporting a sixth axis for DSM-V. Crisis. 2011;32(2):110–113. doi: doi: . doi:10.1027/0227-5910/a000057 [CrossRef]
- Aleman A, Denys D. Mental health: a road map for suicide research and prevention. Nature. 2014;509(7501):421–423. doi:10.1038/509421a [CrossRef]
- Rogers ML, Chiurliza B, Hagan CR, et al. Acute Suicidal Affective Disturbance: factorial structure and initial validation across psychiatric outpatient and inpatient samples. J Affect Disord. 2017;211:1–11. doi: . doi:10.1016/j.jad.2016.12.057 [CrossRef]
- Ribeiro JD, Franklin JC, Fox KR, et al. Self-injurious thoughts and behaviors as risk factors for future suicide ideation, attempts, and death: a meta-analysis of longitudinal studies. Psychol Med. 2016;46(2):225–236. doi: . doi:10.1017/S0033291715001804 [CrossRef]
- Chu C, Klein KM, Buchman-Schmitt JM, Hom MA, Hagan CR, Joiner TE. Routinized assessment of suicide risk in clinical practice: an empirically informed update. J Clin Psychol. 2015;71:1186–1200. doi: . doi:10.1002/jclp.22210 [CrossRef]
- Joiner TE Jr, Walker RL, David M, Jobes DA. Scientizing and routinizing the assessment of suicidality in outpatient practice. Prof Psychol Res Pract. 1999;30(5):447–453. doi: . doi:10.1037/0735-7028.30.5.447 [CrossRef]
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- Yaseen ZS, Chartrand H, Mojtabai R, Bolton J, Galynker II. Fear of dying in panic attacks predicts suicide attempt in comorbid depressive illness: prospective evidence from the National Epidemiological Survey on Alcohol and Related Conditions. Depress Anxiety. 2013;30(10):930–939. doi:10.1002/da.22039 [CrossRef].
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- Hendin H, Al Jurdi RK, Houck PR, Hughes S, Turner JB. Role of intense affects in predicting short-term risk for suicidal behavior: a prospective study. J Nerv Ment Dis. 2010;198(3):220–225. doi: . doi:10.1097/NMD.0b013e3181d13d14 [CrossRef]
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Criterion B for Suicide Crisis Syndrome
|(a) Affective disturbance, as manifested by
| Emotional pain
| Rapid spikes of negative emotions or extreme mood swings
| Extreme anxiety that may be accompanied by dissociation or sensory disturbances, and/or
| Acute anhedonia (ie, a new or increased inability to experience interest or pleasure or imagine future experience of interest or pleasure)
|(b) Loss of cognitive control, as manifested by
| Intense or persistent rumination about one's own distress and the life events that brought on distress
| An inability to deviate from a repetitive negative pattern of thought (cognitive rigidity)
| An experience of an overwhelming profusion of negative thoughts, impairing ability to process information or make a decision (ruminative flood/cognitive overload), and/or
| Repeated unsuccessful attempts to suppress negative or disturbing thoughts
|(c) Disturbance in arousal, as manifested by agitation, hypervigilance, irritability, and/or global insomnia
|(d) Social withdrawal, as manifested by
| Withdrawal from or reduction in scope of social activity, and/or
| Evasive communication with close others