Any thoughts on Suicide Crisis Syndrome?

[R. Matey]

Does anyone know much about the proposed category of Suicide Crisis Syndrome, which attempts to codify a separate DSM disorder for suicidal behavior? The criterion describe a process model of suicide that involves essentially hopelessness, rumination, and panic. The rationale for inclusion is basically so payors will care about it as far as I can tell, but I also just got a brief intro from a recorded lecture recently.

In case you don't know what I'm talking about, here's a systematic review from five years ago that is open access so everyone should be able to see it: https://onlinelibrary.wiley.com/doi/full/10.1111/sltb.13065

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[PsyDr]

It makes sense. We are stuck in the model where SI is de facto evidence of a depressive disorder. But we know the conditional risk of suicide in depressive samples are lower than the manic phase of bipolar disorder, alcohol use disorder, etc. Those things do not coalesce.

If society is going to allow medically assisted suicide, and the laws say you must be free of psychiatric illness before you're allowed to off yourself, then perhaps this area needs to be better addressed in the professional literature.

 

[R. Matey]

It makes sense. We are stuck in the model where SI is de facto evidence of a depressive disorder. But we know the conditional risk of suicide in depressive samples are lower than the manic phase of bipolar disorder, alcohol use disorder, etc. Those things do not coalesce.

As much as I don't like the idea of another 'category' of psychopathology, I tend to agree with you here. What I like about this also is I think it's pretty descriptive of subjective accounts of SI I've heard in therapy.

 

[RxPsych]

The above comments guided me to a tangential path:

I fundamentally disagree with the continued conceptualization of psychopathology as discrete categories, as that's just not how the real world works and I think it's time to move on for various reasons, though I recognize the nearly impassable hurdles to this.
When looking at factor analysis studies (primarily from a dimensional perspective, e.g., Hierarchical Taxonomy Of Psychopathology), it appears suicidality loads strongest onto a distress factor. This makes more sense to me, at least anecdotally, than making the assumption that suicidality is primarily present in internalizing disorders. While distress, at least within the HiTOP model, loads strongest onto internalizing, the benefit of an approach like this is that somebody is not immediately categorized as depressed, bipolar, etc. if they endorse suicidal ideation and at least recognizes the transdiagnostic presence of suicidality. IMO, adding another "diagnosis" of suicidality will likely lead to other negative downstream effects such as stigma, self-efficacy (can you imagine the perspectives people would have on themselves and their capabilities if they were diagnosed with a suicide disorder?), etc.

 

[cara susanna]

Can we get a diagnosis/disorder for Anger Issues That Aren't Attributable to Another Disorder too?

 

[WisNeuro]

Can we get a diagnosis/disorder for Anger Issues That Aren't Attributable to Another Disorder too?

I mean, it's obviously due to unresolved trauma issues, because every negative thing is obviously due to unresolved trauma.

 

[PsyDr]

Clearly, being angry is evidence that someone is anxious or depressed. Unless someone is autistic, psychotic, or demented.

No one ever has anger issues because the environment reinforces that behavior. And narcissistic rage isn't a thing.

Funny how diagnoses are informed by the available interventions.

 

[Sanman]

In practice, I am not so sure of the utility of such a diagnosis. I think two of the biggest questions remain unanswered:

1. How long is one in a Suicide Crisis Syndrome state prior to suicidal behavior? If we we are talking weeks or months there is utility. If we are talking hours, much less utility outside of an ER.

2. What percentage of those with SCS or even suicidal ideation, convert to suicidal behavior. Certainly, the thoughts cross the minds of many people that do not act on them. If you diagnose SCS, what is the intervention? Will you be forced to hospitalize for liability reasons or will there be other uses?

 

[cara susanna]

In practice, I am not so sure of the utility of such a diagnosis. I think two of the biggest questions remain unanswered:

1. How long is one in a Suicide Crisis Syndrome state prior to suicidal behavior? If we we are talking weeks or months there is utility. If we are talking hours, much less utility outside of an ER.

2. What percentage of those with SCS or even suicidal ideation, convert to suicidal behavior. Certainly, the thoughts cross the minds of many people that do not act on them. If you diagnose SCS, what is the intervention? Will you be forced to hospitalize for liability reasons or will there be other uses?

That's a good point: we have research showing that ideation doesn't usually translate into behavior (which is why we're so bad at predicting suicidal behavior. Suicidal ideation we're great at)

 

[albatross_at_crossroads]

Clearly, being angry is evidence that someone is anxious or depressed. Unless someone is autistic, psychotic, or demented.

No one ever has anger issues because the environment reinforces that behavior. And narcissistic rage isn't a thing.

Funny how diagnoses are informed by the available interventions.

Sorry to sidetrack the conversation, but why do you say that narcissistic rage "isn't a thing"? Do you mean that it's just a set of behaviors that arise from the symptoms of the disorder that get interpreted as "rage"?

 

[PsyDr]

Sorry to sidetrack the conversation, but why do you say that narcissistic rage "isn't a thing"? Do you mean that it's just a set of behaviors that arise from the symptoms of the disorder that get interpreted as "rage"?

I was being sarcastic. Sorry, I should have used the “/s” thing.

 

[albatross_at_crossroads]

I was being sarcastic. Sorry, I should have used the “/s” thing.

Now it makes sense; somehow I keep taking you at your word, forgot about the sarcasm

That's a good point: we have research showing that ideation doesn't usually translate into behavior (which is why we're so bad at predicting suicidal behavior. Suicidal ideation we're great at)

I totally agree with not being as good at predicting suicidal behavior. I am unsure whether a diagnosis would attract more research to the topic to help with this.

 

[EnPsychlopedia]

That's a good point: we have research showing that ideation doesn't usually translate into behavior (which is why we're so bad at predicting suicidal behavior. Suicidal ideation we're great at)

Kelly Posner is doing a lot of work on trying to remedy this. I know that we are not anywhere near as good as we need to be, but my understanding is the C-SSRS has improved predictive validity at least marginally...

 

[LM02]

Kelly Posner is doing a lot of work on trying to remedy this. I know that we are not anywhere near as good as we need to be, but my understanding is the C-SSRS has improved predictive validity at least marginally...

The C-SSRS is not going to solve this problem for us as a field.

 

[borne_before]

Here's the proposed criteria:

(A) Entrapment	A persistent or recurring overwhelming feeling of urgency to escape or avoid an unacceptable life situation that is perceived to be impossible to escape, avoid, or endure SCI: scoring ≥39 points on the entrapment subscale
Criterion B
(B1) Affective disturbance	Manifested by at least one of the four symptoms: (1) Intense feelings of emotional pain (e.g., “sense of inner pain that was too much to bear”) SCI: scoring ≥12 points on the emotional pain subscale (2) Rapid spikes of negative emotions (e.g., feeling “unusually intense or deep negative feelings or mood swings towards someone else”) SCI: scoring ≥4 points on the rapid spikes of negative emotions subscale (3) Extreme anxiety (e.g., “Did you have strange sensations in your body or on your skin?”) SCI: ≥ 3 points on item 1 (nervousness and shakiness) of the Brief Symptom Inventory (BSI; Derogatis & Melisaratos, 1983) (4) Acute anhedonia (e.g. “Did you feel dissatisfied or bored with everything?”) SCI: scoring ≥3 points on the combined score of item 4 (loss of pleasure) and item 12 (loss of interest) of the Beck Depression Inventory (BDI; Beck & Steer, 1987)
(B2) Loss of cognitive control	Manifested by at least one of the following: (1) Rumination (e.g., “Ideas kept turning over and over in your mind”) SCI: scoring ≥2 points on item 34 of the SCI (2) Cognitive rigidity (e.g., “Did you feel your views were very consistent over time?”) SCI: threshold not indicated (item newly added to the SCI-2) (3) Ruminative flooding (e.g., feeling “pressure in your head from thinking too much”) SCI: scoring ≥14 points on the 7-item subscale (4) Failed thought suppression (e.g., “Did you want troubling thoughts to go away but they wouldn't?”) SCI: scoring ≥3 points on item 39 (wanted troubling thoughts to go away) or 40 (felt powerless to stop upsetting thoughts) of SCI
(B3) Hyperarousal	Manifested by at least one of the following: (1) Feelings of agitation (e.g. “Did you feel so restless you could not sit still?”) SCI: scoring ≥4 points on either item 38 (feeling “tensed or keyed up”) or item 49 (feeling “restless you could not sit still”) of the BSI. (2) Hypervigilance (e.g., “Did you feel you were constantly watching for signs of trouble?”) SCI: scoring ≥4 points on item 10 (feeling “that most people could not be trusted”) of the BSI. (3) Irritability (e.g “Did you feel easily annoyed or irritated?”) SCI: scoring ≥4 points on item 6 (feeling “easily annoyed or irritated”) of the BSI. (4) Insomnia (e.g., “Did you wake up from sleep tired and not refreshed?”) SCI: scoring ≥3 points on either item 1 (waking up “tired and not refreshed”) or item 15 (“trouble fallings asleep because of uncontrollable thoughts”) of the SCI
(B4) Social withdrawal	Manifested by at least one of the following: Avoidance of social interactions and feelings of isolation (1) Withdrawal from or reduction in scope of social activity SCI-2: scoring <2 points on a single item of social connectedness (feeling “isolated from others”) (2) Evasive communication with close others SCI-2: scoring unclear (evading communication “with people who care about you”)

 

[EnPsychlopedia]

The C-SSRS is not going to solve this problem for us as a field.

No, it definitely won't. I'm not suggesting it will.

 

[R. Matey]

No, it definitely won't. I'm not suggesting it will.

The problem really is not the scale itself, but rather the implementation in whatever healthcare system to do things that it probably wasn't ever designed to do. The C-SSRS is a pretty good scale psychometrically, but giving it week-after-week-after-week-after-week alongside a packet of 14 other instruments is going to result in measurement error due to things like survey fatigue, order effects, and familiarity with the measure.

 

[cara susanna]

Here's the proposed criteria:

(A) Entrapment	A persistent or recurring overwhelming feeling of urgency to escape or avoid an unacceptable life situation that is perceived to be impossible to escape, avoid, or endure SCI: scoring ≥39 points on the entrapment subscale
Criterion B
(B1) Affective disturbance	Manifested by at least one of the four symptoms: (1) Intense feelings of emotional pain (e.g., “sense of inner pain that was too much to bear”) SCI: scoring ≥12 points on the emotional pain subscale (2) Rapid spikes of negative emotions (e.g., feeling “unusually intense or deep negative feelings or mood swings towards someone else”) SCI: scoring ≥4 points on the rapid spikes of negative emotions subscale (3) Extreme anxiety (e.g., “Did you have strange sensations in your body or on your skin?”) SCI: ≥ 3 points on item 1 (nervousness and shakiness) of the Brief Symptom Inventory (BSI; Derogatis & Melisaratos, 1983) (4) Acute anhedonia (e.g. “Did you feel dissatisfied or bored with everything?”) SCI: scoring ≥3 points on the combined score of item 4 (loss of pleasure) and item 12 (loss of interest) of the Beck Depression Inventory (BDI; Beck & Steer, 1987)
(B2) Loss of cognitive control	Manifested by at least one of the following: (1) Rumination (e.g., “Ideas kept turning over and over in your mind”) SCI: scoring ≥2 points on item 34 of the SCI (2) Cognitive rigidity (e.g., “Did you feel your views were very consistent over time?”) SCI: threshold not indicated (item newly added to the SCI-2) (3) Ruminative flooding (e.g., feeling “pressure in your head from thinking too much”) SCI: scoring ≥14 points on the 7-item subscale (4) Failed thought suppression (e.g., “Did you want troubling thoughts to go away but they wouldn't?”) SCI: scoring ≥3 points on item 39 (wanted troubling thoughts to go away) or 40 (felt powerless to stop upsetting thoughts) of SCI
(B3) Hyperarousal	Manifested by at least one of the following: (1) Feelings of agitation (e.g. “Did you feel so restless you could not sit still?”) SCI: scoring ≥4 points on either item 38 (feeling “tensed or keyed up”) or item 49 (feeling “restless you could not sit still”) of the BSI. (2) Hypervigilance (e.g., “Did you feel you were constantly watching for signs of trouble?”) SCI: scoring ≥4 points on item 10 (feeling “that most people could not be trusted”) of the BSI. (3) Irritability (e.g “Did you feel easily annoyed or irritated?”) SCI: scoring ≥4 points on item 6 (feeling “easily annoyed or irritated”) of the BSI. (4) Insomnia (e.g., “Did you wake up from sleep tired and not refreshed?”) SCI: scoring ≥3 points on either item 1 (waking up “tired and not refreshed”) or item 15 (“trouble fallings asleep because of uncontrollable thoughts”) of the SCI
(B4) Social withdrawal	Manifested by at least one of the following: Avoidance of social interactions and feelings of isolation (1) Withdrawal from or reduction in scope of social activity SCI-2: scoring <2 points on a single item of social connectedness (feeling “isolated from others”) (2) Evasive communication with close others SCI-2: scoring unclear (evading communication “with people who care about you”)

Okay, two thoughts here...

1) This doesn't seem very specific
2) Where did the hyperarousal thing come from?

 

[EnPsychlopedia]

The problem really is not the scale itself, but rather the implementation in whatever healthcare system to do things that it probably wasn't ever designed to do. The C-SSRS is a pretty good scale psychometrically, but giving it week-after-week-after-week-after-week alongside a packet of 14 other instruments is going to result in measurement error due to things like survey fatigue, order effects, and familiarity with the measure.

I completely agree! I think implementation is a major barrier to the C-SSRS working as well in practice as its psychometrics suggest that it should.

 

[R. Matey]

Okay, two thoughts here...

1) This doesn't seem very specific
2) Where did the hyperarousal thing come from?

Re #2: I think they added it later based on trying separate out the emotive effects of rumination. At least that's what I got from skimming the following reference:

The revised suicide crisis inventory (SCI-2): Validation and assessment of prospective suicidal outcomes at one month follow-up - PubMed

The results of this study indicate that the SCI-2 is a valid and reliable tool to assess the presence and intensity of the Suicide Crisis Syndrome and to predict short-term prospective suicidal behaviors and attempts among psychiatric outpatients and inpatients regardless of patients' readiness...

pubmed.ncbi.nlm.nih.gov

 

[aim-agm]

How would this be materially different than an adjustment disorder?

 

[WisNeuro]

How would this be materially different than an adjustment disorder?