Rethinking Suicidal Behavior Disorder
Abstract
Abstract.Background: It is a peculiar fact that the deadliest psychiatric disturbance – suicidality – cannot be formally diagnosed. Suicidal behavior disorder (SBD), a condition for further study in the DSM-5, is the field's first attempt to capture suicidality in a diagnosis. Aims: To provoke discussion about the standing of suicidality as a diagnosable psychiatric condition. Method: I present pragmatic and conceptual rationales for why a diagnosis of suicidality is clinically useful but conclude that SBD does little to aid clinicians in assessing suicidality's symptoms, planning treatment, or monitoring progress. Results: To improve the clinical utility of SBD, I re-conceptualize it from the vantage point of descriptive psychiatry. I hypothesize that this revised SBD is an independent, episodic, and frequently co-occurring condition and propose new cognitive, affective, and behavioral criteria that more completely capture the phenomenology of suicidality. Conclusion: The revised SBD is a starting place for dialogue about whether a clinically significant presentation of suicidality is a mental illness and, if it is, what its defining features should be.
References
2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
. (2011).
(Psychopharmacology for suicide prevention . In M. PompiliR. TatarelliEds., Evidence-based practice in suicidology: A source book (pp. 243–264). Cambridge, MA: Hogrefe Publishing.1990). Suicide as escape from self. Psychological Review, 97(1), 90–113. 10.1037/0033-295X.97.1.90
(1986).
(Development of Suicidal Intent Scales. In A. T. BeckH. L. P. ResnikD. J. LettieriEds., The prediction of suicide (pp. 45–56). Philadelphia, PA: Charles Press.2017). Objectively assessed sleep variability as an acute warning sign of suicidal ideation in a longitudinal evaluation of young adults at high suicide risk. Journal of Clinical Psychiatry, 78(6), e678–e687. 10.4088/JCP.16m11193
(2016). Suicide attempt as a risk factor for completed suicide: Even more lethal than we knew. American Journal of Psychiatry, 173(11), 1094–1100. 10.1176/appi.ajp.2016.15070854
(2006). Advances in the assessment of suicide risk. Journal of Clinical Psychology, 62(2), 185–200. 10.1002/jclp.20222
(2003). Clinical correlates of inpatient suicide. Journal of Clinical Psychiatry, 64(1), 14–19.
(2016). Emergency department visits for attempted suicide and self harm in the USA: 2006–2013. Epidemiology and Psychiatric Sciences, 27, 94–102. 10.1017/S2045796016000871
(2014). Hospital presenting self-harm and risk of fatal and non-fatal repetition: Systematic review and meta-analysis. PLoS One, 9(2), e89944. 10.1371/journal.pone.0089944
(2016). Geographical and temporal variations in the prevalence of mental disorders in suicide: Systematic review and meta-analysis. Journal of Affective Disorders, 190, 704–713. 10.1016/j.jad.2015.11.008
(2013). The effects of psychotherapy for adult depression on suicidality and hopelessness: A systematic review and meta-analysis. Journal of Affective Disorders, 144(3), 183–190. 10.1016/j.jad.2012.06.025
(2006). Definitions of suicidal behavior: Lessons learned from the WHO/EURO Multicentre Study. Crisis, 27(1), 4–15. 10.1027/0227-5910.27.1.4
(2015). From the serotonin model of suicide to a mental pain model of suicide. Psychotherapy and Psychosomatics, 84(6), 323–329. 10.1159/000438510
(2013). VA/DoD clinical practice guideline for assessment and management of patients at risk for suicide. Washington, DC: US Department of Veterans Affairs.
. (1996). Choosing to live: How to defeat suicide through cognitive therapy. Oakland, CA: New Harbinger Publications.
(2011). Treatment of co-occurring substance abuse and suicidality among adolescents: A randomized trial. Journal of Consulting and Clinical Psychology, 79(6), 728–739. 10.1037/a0026074
(2010). An overview of mood disorders in the DSM-5. Current Psychiatry Reports, 12(6), 531–538. 10.1007/s11920-010-0154-2
(2016). Sleep disturbance as a proximal predictor of suicidal intent in recently hospitalized attempters. Sleep Medicine, 19, 1–7. 10.1016/j.sleep.2015.10.021
(2010). Clinical utility in the revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM). Professional Psychology: Research and Practice, 41(6), 465. 10.1037/a0021511
(2004). Clinical utility as a criterion for revising psychiatric diagnoses. American Journal of Psychiatry, 161(6), 946–954. 10.1176/appi.ajp.161.6.946
(2004). History of multiple suicide attempts as a behavioral marker of severe psychopathology. American Journal of Psychiatry, 161(3), 437–443. 10.1176/appi.ajp.161.3.437
(2017). Risk factors for suicidal thoughts and behaviors: A meta-analysis of 50 years of research. Psychological Bulletin, 143(2), 187–232. 10.1037/bul0000084
(2017). Prediction of suicidal behavior in high risk psychiatric patients using an assessment of acute suicidal state: The suicide crisis inventory. Depression and Anxiety, 34(2), 147–158. 10.1002/da.22559
(2013). Trust is the basis for effective suicide risk screening and assessment in veterans. Journal of General Internal Medicine, 28(9), 1215–1221. 10.1007/s11606-013-2412-6
(1992). Why psychiatry is a branch of medicine. New York, NY: Oxford University Press.
(2010).
(Preface to the first edition. In C. S. NorthS. H. YutzyEds., Goodwin and Guze's psychiatric diagnosis (6th ed., pp. xv–xvii). New York, NY: Oxford University Press.1997). Suicide as an outcome for mental disorders: A meta-analysis. The British Journal of Psychiatry, 170(3), 205–228. 10.1192/bjp.170.3.205
(2010). The internal suicide debate hypothesis: Exploring the life versus death struggle. Suicide and Life-Threatening Behavior, 40(2), 181–192. 10.1521/suli.2010.40.2.181
(2015). The ABC's of suicide risk assessment: Applying a tripartite approach to individual evaluations. PLoS One, 10(6), e0127442. 10.1371/journal.pone.0127442
(2013). Psychiatric disorders in patients presenting to hospital following self-harm: A systematic review. Journal of Affective Disorders, 151(3), 821–830. 10.1016/j.jad.2013.08.020
(2015).
(What we know and don't know about treating suicide risk. In C. J. BryanEd., Cognitive behavioral therapy for preventing suicide attempts: A guide to brief treatments across clinical settings (pp. 33–47). New York, NY: Routledge.1999). Conceptual confusion about intentions and motives of nonfatal suicidal behavior: A discussion of terms employed in the literature of suicidology. Archives of Suicide Research, 5(4), 277–283. 10.1023/A:1009685700347
(2011). Chronic readiness questionnaire, Version 2.0. Vacaville, CA: Department of State Hospitals.
(2016). Psychiatric classifications: Validity and utility. World Psychiatry, 15(1), 26–31. 10.1002/wps.20284
(2016). Managing suicidal risk: A collaborative approach (2nd ed.). New York, NY: Guilford.
(1987). Improving the validity and reliability of medical-legal certifications of suicide. Suicide and Life-Threatening Behavior, 17(4), 310–325.
(2005). Four studies on how past and current suicidality relate even when "everything but the kitchen sink" is covaried. Journal of Abnormal Psychology, 114(2), 291–303. 10.1037/0021-843X.114.2.291
(2016). Detecting and treating suicide ideation in all settings. Sentinel Event Alert, 56, 1–7.
. (2015). The three-step theory (3ST): A new theory of suicide rooted in the ideation-to-action framework. International Journal of Cognitive Therapy, 8(2), 114–129. 10.1521/ijct.2015.8.2.114
(2017). Recent advances in differentiating suicide attempters from suicide ideators. Current Opinion in Psychiatry, 30(1), 15–20. 10.1097/YCO.0000000000000294
(2015). Metasynthesis of youth suicidal behaviours: Perspectives of youth, parents, and health care professionals. PLoS One, 10(5), e0127359. 10.1371/journal.pone.0127359
(1993). Cognitive-behavioral treatment of borderline personality disorder. New York, NY: Guilford.
(1986). Suicide risk: The formulation of clinical judgment. New York, NY: New York University Press.
(2004). The descent into suicide. International Journal of Psychoanalysis, 85(3), 653–667. 10.1516/3C96-URET-TLWX-6LWU
(2015). Suicide studies today. Where do we come from? Who are we? Where are we going? Crisis, 36(6), 387–389. 10.1027/0227-5910/a000338
(2015).
(The language of suicide. In C. J. BryanEd., Cognitive behavioral therapy for preventing suicide attempts: A guide to brief treatments across clinical settings (pp. 14–32). New York, NY: Routledge.2013). Assessing motivations for suicide attempts: Development and psychometric properties of the inventory of motivations for suicide attempts. Suicide and Life-Threatening Behavior, 43(5), 532–546. 10.1111/sltb.12037
(2007). Can we predict suicide and non-fatal self-harm with the Beck Hopelessness Scale? A meta-analysis. Psychological Medicine, 37(6), 769–778. 10.1017/S0033291706009664
(2011). Assessment of psychological pain in major depressive episodes. Journal of Psychiatric Research, 45(11), 1504–1510. 10.1016/j.jpsychires.2011.06.011
(2006). Psychological pain: A review of evidence. Journal of Psychiatric Research, 40(8), 680–690. 10.1016/j.jpsychires.2006.03.003
(2016). Direct versus indirect psychosocial and behavioural interventions to prevent suicide and suicide attempts: A systematic review and meta-analysis. Lancet Psychiatry, 3(6), 544–554. 10.1016/S2215-0366(16)00064-X
(2014). Toward a unifying definition: Response to 'The concept of mental pain'. Psychotherapy and Psychosomatics, 83(1), 62–63. 10.1159/000348869
(2002). Discovering the truth in attempted suicide. American Journal of Psychotherapy, 56(3), 424–437.
(2008). Cross-national prevalence and risk factors for suicidal ideation, plans and attempts. British Journal of Psychiatry, 192(2), 98–105. 10.1192/bjp.bp.107.040113
(1996). Beyond the Tower of Babel: A nomenclature for suicidology. Suicide and Life-Threatening Behavior, 26(3), 237–252.
(2014). Suicidal behavior disorder as a diagnostic entity in the DSM-5 classification system: Advantages outweigh limitations. World Psychiatry, 13(2), 128–130. 10.1002/wps.20116
(2009). Can novel nosological strategies aid in the identification of risk for suicidal behavior? Crisis, 30(4), 171–173. 10.1027/0227-5910.30.4.171
(2014). Toward a biosignature for suicide. American Journal of Psychiatry, 171(12), 1259–1277. 10.1176/appi.ajp.2014.14020194
(2003). Mental pain: A multidimensional operationalization and definition. Suicide and Life-Threatening Behavior, 33(3), 219–230.
(2014).
(The classification of suicidal behavior. In M. K. NockEd., The Oxford handbook of suicide and self-injury (pp. 7–22). New York, NY: Oxford University Press.2007). Columbia Classification Algorithm of Suicide Assessment (C-CASA): Classification of suicidal events in the FDA's pediatric suicidal risk analysis of antidepressants. American Journal of Psychiatry, 164(7), 1035–1043. 10.1176/ajp.2007.164.7.1035
(2006).
(Problem solving: A conceptual approach to suicidality and psychotherapy. In T. E. EllisEd., Cognition and suicide: Theory, research, and therapy (pp. 237–260). Washington, DC: American Psychological Association.2014). Fearlessness about death: The psychometric properties and construct validity of the revision to the acquired capability for suicide scale. Psychological Assessment, 26(1), 115–126. 10.1037/a0034858
(2016). How do clinicians and suicide attempters understand suicide attempt impulsivity? A qualitative study. Death Studies, 40(3), 139–146. 10.1080/07481187.2015.1096314
(1976). The presuicidal syndrome. Suicide and Life-Threatening Behavior, 6(3), 131–149.
(2006).
(Fluid vulnerability theory: A cognitive approach to understanding the process of acute and chronic suicide risk. In T. E. EllisEd., Cognition and suicide: Theory, research, and therapy (pp. 355–368). Washington, DC: American Psychological Association.2008). Suicide warning signs in clinical practice. Current Psychiatry Reports, 10(1), 87–90. 10.1007/s11920-008-0015-4
(2009). Informed consent with suicidal patients: Rethinking risks in (and out of) treatment. Psychotherapy: Theory, Research, Practice, Training, 46(4), 459–468. 10.1037/a0017902
(1999). The outpatient treatment of suicidality: An integration of science and recognition of its limitations. Professional Psychology: Research and Practice, 30(5), 437–446. 10.1037/0735-7028.30.5.437
(2012). Preventing suicide through improved training in suicide risk assessment and care: An American Association of Suicidology Task Force report addressing serious gaps in U.S. mental health training. Suicide and Life-Threatening Behavior, 42(3), 292–304. 10.1111/j.1943-278X.2012.00090.x
(1998). The suicidal mind. New York, NY: Oxford University Press.
(2007). Rebuilding the Tower of Babel: A revised nomenclature for the study of suicide and suicidal behaviors: Part 2: Suicide-related ideations, communications and behaviors. Suicide and Life-Threatening Behavior, 37(3), 264–277. 10.1521/suli.2007.37.3.264
(2009). Persistent nightmares are associated with repeat suicide attempt: A prospective study. Psychiatry Research, 170(2–3), 208–211. 10.1016/j.psychres.2008.09.006
(2016). An aspect of the capability for suicide-fearlessness of the pain involved in dying-amplifies the association between suicide ideation and attempts. Archives of Suicide Research, 20(4), 650–662. 10.1080/13811118.2016.1162245
(2017). Suicide risk assessment: What psychologists should know. Professional Psychology: Research and Practice, 48(2), 98–106. 10.1037/pro0000106
(2010). What is a mental/psychiatric disorder? From DSM-IV to DSM-V. Psychological Medicine, 40, 1759–1765. 10.1017/S0033291709992261
(2017). Biomarkers of suicide attempt behavior: Towards a biological model of risk. Current Psychiatry Reports, 19(6), 31. 10.1007/s11920-017-0781-y
(2000).
(Psychiatric diagnoses and suicidal acts. In R. W. MarisA. L. BermanM. M. SilvermanEds., Comprehensive textbook of suicidology (pp. 311–341). New York, NY: Guilford.2013). The concept of mental pain. Psychotherapy and Psychosomatics, 82(2), 67–73. 10.1159/000343003
(2016). Construct validity of a proposed new diagnostic entity: Acute suicidal affective disturbance (ASAD). Journal of Affective Disorders, 189, 365–378. 10.1016/j.jad.2015.07.049
(2010). The interpersonal theory of suicide. Psychological Review, 117(2), 575–600. 10.1037/a0018697
(2016). Mental pain and suicide: A systematic review of the literature. Front Psychiatry, 7, 108. 10.3389/fpsyt.2016.00108
(2009). Cognitive therapy for suicidal patients: Scientific and clinical applications (1st ed.). Washington, DC: American Psychological Association.
(