Jun 17, 2020
Igor Galynker, MD, returns to the Psychcast, this time to
discuss his most recent work on suicidal crisis syndrome with host
Lorenzo Norris, MD.
Galynker is professor of psychiatry and director of the
Research and Prevention Laboratory at the Icahn School of
Medicine at Mount Sinai, New York. He reported receiving funding
from the National Institute of Mental Health and the American
Foundation for Suicide Prevention. Dr. Norris has no
- Suicide crisis syndrome (SCS) is a state or syndrome that
develops shortly before a suicide attempt. Since the last Psychcast
with Dr. Galynker, SCS has been replicated in several cohorts and
- SCS has been refined to three primary factors instead of five.
The factors of SCS include a state of entrapment which includes
cognitive rigidity and flooding, insomnia/agitation, and social
- New data are emerging about how to treat the acute syndrome
with medications, because patients are not susceptible to
psychotherapy or even safety planning in this state of mind.
- Galynker and colleagues have validated the suicide crisis
narrative model and have found that the clinician’s response to the
narrative is predictive of risk of suicide.
- In SCS, the two primary factors are a sense of entrapment and
cognitive rigidity followed by insomnia or agitation and social
- The state of entrapment is characterized by frantic
hopelessness with a sense of being trapped in a life situation that
is painful, intolerable, and feeling that all escapes are blocked.
Cognitive rigidity and dyscontrol can include ruminative flooding
associated with headache or head pressure, and inability to
suppress the ruminative thoughts. Cognitive rigidity, like
psychosis, can make it difficult to engage in psychotherapy.
- SCS needs to be treated with medications such as an
antipsychotic for cognitive rigidity, a benzodiazepine for the
frantic hopelessness and sense of agitation, and something that
targets the emotional pain.
- Antidepressants might make SCS worse because they can increase
- The accompanying narrative crisis model of suicide behavior
includes five components: High-risk traits, stressful life events,
a narrative of hopelessness and failure, the suicide crisis
syndrome, and then suicide attempt. Clinicians can think of the
long-term risk factors for suicide as vulnerable traits such as
fearlessness, perfectionism, insecure attachment, and childhood
abuse. When these vulnerable individuals have stressful life
events, they enter a subacute phase in which they create a life
narrative that tells a story of falling short of their goals,
feeling humiliation, being a burden to others, and being unable to
achieve future goals, all of which lead to social withdrawal.
- SCS is treated with medications and means restriction, and the
narrative is treated with cognitive restructuring through specific
forms of psychotherapy.
- Three clinician emotions triggered by a suicidal patient’s
narrative are predictive of risk of suicide death. The first
emotion is clinician distress and dread. The second is anxious
overinvolvement, which is similar to a rescue fantasy with false
hope. The third is a sense of distancing and resignation that the
patient is going to kill themselves. Clinicians must be trained to
listen to their own emotional reactions to a patient's suicidal
narrative of how they arrived at this state to detect this
- Using emotions and something like the SCS is important for
suicide prevention, because only one-third of people report
suicidal ideation. Sometimes the burden of EMR documentation or
checkboxes can get in the way of accurately assessing a patient’s
risk. This type of work requires awareness of emotions and managing
them to make sure they are attuned to the patient. Other emotions,
such as fatigue and burnout, can interfere with the risk
Cohen LJ et al. Suicide Life Threat
Behav. 2019 Apr;49(2):413-22.
Hawes M et al. Compr Psychiatry. 2017
Galynker I et al. Depress Anxiety. 2017
Show notes by Jacqueline Posada, MD, who is associate producer
of the Psychcast and consultation-liaison psychiatry fellow with
the Inova Fairfax Hospital/George Washington University program in
Falls Church, Va. Dr. Posada has no conflicts of interest.
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