Jul 31, 2019
Galynker, MD, PhD, talks with Lorenzo
Norris, MD, host of the MDedge Psychcast and editor in chief of
MDedge Psychiatry, about suicide crisis syndrome.
Dr. Galynker has been a guest on the Psychcast twice before,
once to discuss the impact of suicide on physicians and a
time to talk about his research on the arguments for adding a
suicide-specific diagnosis to the DSM-5. He is associate chairman
for research in the department of psychiatry at Mount Sinai Beth
Israel in New York. In addition, Dr. Galynker is founder and
director of the Richard and Cynthia Zirinsky Center for Bipolar
Disorder, and professor of psychiatry at the Icahn School of
Medicine, both at Mount Sinai.
Show Notes by Jacqueline Posada, MD, who is a
consultation-liaison psychiatry fellow with the Inova Fairfax
Hospital/George Washington University program in Falls Church,
Later, in the “Dr. RK” segment, Renee Kohanski, MD, tells the story
of a patient who found a way to rediscover his value system against
great odds. Dr. Kohanski, a member of the MDedge Psychiatry
Editorial Advisory Board, is a psychiatrist in private practice in
Suicide crisis syndrome: A suicide-specific mental
- Until recently, there was no differentiation between the mental
state associated with lifelong suicide risk versus the mental state
associated with imminent suicide risk.
Fawcett, MD, distinguished these mental states for the first
time by differentiating acute risk of imminent death and lifelong
risks and traits of suicidal behavior.
- Lifetime suicide risk factors include mental illness, history
of suicide attempts, depression, and substance abuse.
- Imminent suicidal behavior risk factors include panic, acute
anhedonia, agitation, and insomnia.
Dr. Galynker and colleagues have identified a condition they
call suicide crisis syndrome, which they define as a mental state
that predicts imminent suicidal behavior in days to weeks. The
predictive validity has been replicated across several cultures and
Suicide crisis syndrome: To be identified as
having suicide crisis syndrome, the patient must meet both
criterion A and two criteria of B.
- Criterion A: Frantic hopelessness or state of entrapment
defined as being stuck in a life situation that is painful and
intolerable, and a feeling that all routes of escape are
blocked. The risk of suicide within 1 month is 13% for people
who meet criteria for suicide crisis syndrome.
- Criterion B:
- Affective dyscontrol, including emotional pain or mental pain;
severe panic with agitation, and dissociation; rapid mood swings
that can include happiness; and acute anhedonia.
- Cognitive dyscontrol, which can include ruminative flooding
associated with headache or head pressure; cognitive rigidity; and
inability to suppress the ruminative thoughts. (For example, you
might assess by asking: “Do you control the thoughts or do the
thoughts control you?”)
- Overarousal with insomnia and agitation.
- Social withdrawal and isolation, and evading
Why are suicide-specific diagnoses
- 75% of people who die by suicide do not report suicidal
ideation to a clinician, psychiatrist, or primary care
- Notably, suicide crisis syndrome does not include suicidal
ideation in the criteria, because not all people within imminent
risk feel suicidal until the moment strikes. Some patients will
hide their suicidal ideation from their clinician to prevent having
their plan foiled.
- Suicide crisis syndrome creates a fuller picture of patient
risk. Assessment of the criteria help a clinician consider more
risk factors for imminent risk than simply a patient’s self-report
about suicidal ideation.
Approach suicidality with a different
- Suicide-specific diagnoses represent a profound shift in
approach, because suicide is a transdiagnostic phenomenon for
depression, bipolar disorder, and schizophrenia.
- A person can be at imminent risk for suicide without meeting
criteria for other DSM diagnoses.
- Other suicide-specific diagnoses: Maria
A. Oquendo, MD, PhD, and colleagues have put forward “suicidal
behavior disorder,” which is a diagnosis that captures the
propensity of suicidal behavior and urges to kill oneself.
- Suicidal behavior disorder and suicide crisis syndrome provide
clinical targets for treatment of suicide.
- Without a diagnosis, clinicians cannot test treatment or teach
Use emotional reactions to the patient in suicide risk
- Clinicians can identify “gut feelings” that help hone their
- Galynker and colleagues have identified four emotions that can
help clinicians identify suicide risk:
- Dislike with distancing.
- Anxious overinvolvement, with a paradoxical combination of hope
- Collusion/abandonment/rejection, which includes a type of
hopelessness and calm.
- Clinicians can be trained to identify these emotions, which
they may have been taught to suppress.
- Recognition of these emotions can be cultivated through
“emotional awareness rounds.”
Dr. Fawcett is a professor of psychiatry at the University of
New Mexico, Albuquerque. Dr. Oquendo is the Ruth Meltzer Professor
of Psychiatry at the University of Pennsylvania, Philadelphia.
Olfson M et al. Short-term suicide risk after psychiatric
hospital discharge. JAMA Psychiatry.
2016 Nov 1;73(11):1119-26.
Galynker I et al. Prediction of suicidal behavior in high-risk
psychiatric patients using an assessment of acute suicidal state:
The suicide crisis inventory. Depress Anxiety. 2017
Cohen LJ et al. The suicide crisis syndrome mediates the
relationship between long-term risk factors and lifetime suicidal
phenomena. Suicide Life Threat
Behav. 2018 Oct;48(5):613-23.
Suicide rising across U.S. Centers for Disease Control and
Prevention. Vital Signs. 2018 Jun.
Oquendo MA and E Baca-Garcia. Suicidal behavior disorder as a
diagnostic entity in the DSM-5 classification system: advantages
outweigh limitations. World Psychiatry. 2014
Fawcett J. “Diagnosis, traits, states and comorbidity in
suicide” in The Neurobiological Basis of
Suicide. Boca Raton, Fla.: Taylor & Francis, 2012.
For more MDedge Podcasts, go to
Email the show: email@example.com
Interact with us on Twitter: @MDedgePsych