Experts Argue for Addition of Suicide-Specific Diagnoses in DSM

A discrete, specific diagnosis of suicidal behavior disorder could be enormously clinically useful, helping to identify at-risk patients for treatment and aiding in research on suicide, according to former APA president and suicide expert Maria A. Oquendo, M.D., Ph.D., at APA’s 2019 Annual Meeting in San Francisco last month.

David Hathcox

“Suicidal behavior disorder” is included in Section III of DSM-5 as a diagnosis requiring more research. Oquendo and colleagues argued that inclusion of the diagnosis in the main text as an approved diagnosis would help solve a number of clinical and systemic problems associated with identifying patients at risk for suicide. Oquendo is chair of the Department of Psychiatry at the University of Pennsylvania Perelman School of Medicine and a director on the National Board of the American Foundation for Suicide Prevention. She is also immediate past president of the International Academy of Suicide Research.

(The APA Board of Trustees and DSM Steering Committee, chaired by past APA President Paul Appelbaum, M.D., have established a process for updating the diagnostic manual as new research becomes available. See end of article for website information.)

Oquendo said that during an assessment, clinicians seek to make the primary diagnosis responsible for the chief complaint and use overview questions to identify comorbid conditions. If they do not find evidence for a major depressive episode or borderline personality disorder—two conditions for which DSM criteria include suicidality as a symptom—questions about suicidal behavior may not be asked.

“While institutions today generally require suicide screening for psychiatric cases, many patients are seen in other settings that may not,” she said.

Moreover, since the Mental Status Examination targets patients’ present state, those denying suicidal ideation may not be asked about past suicidal acts. This results in underestimating the number of suicidal cases.

“A history of suicidal behavior is the most reliably replicated risk factor for future suicide attempt or completion, whereas expressions of suicidality wax and wane and may be absent during an interview,” Oquendo said.

For that reason, current diagnostic algorithms may lead clinicians to overlook suicidal ideation or behavior in patients with posttraumatic stress disorder, where patients may contemplate suicide as an escape from their flashbacks, or in those with alcoholism, where disinhibition during intoxication may render patients less able to resist suicidal thoughts. Even when clinicians identify suicidal ideation or behavior, patients may receive a diagnosis that does not highlight suicide risk as a focus of concern, she said.

Most importantly, clinical studies demonstrate that information on suicide risk is often lost when patients are “handed off” in inpatient settings—that is, when patients are passed from one treatment team or clinician to another. Moreover, electronic medical records encourage standardized patient descriptions, which may lead clinicians to rely more heavily on diagnostic codes when devising treatment plans.

Oquendo said suicidal behavior meets criteria for diagnostic validity: It is clinically well described, research has identified postmortem and in vivo laboratory markers, it can be subjected to a strict differential diagnosis, follow-up studies confirm its presence at higher rates in those with a past diagnosis, and it is familial.

In addition, she said the existence of a suicide-specific diagnosis would compel clinical and administrative structures to determine the suicide risk status of individuals assessed in psychiatric settings. “The presence of suicidal behavior can be documented in the medical record with the prominence that it deserves in written reports, allowing for treatment planning for vulnerable patients,” she said.

“For research purposes, a diagnosis would more reliably identify cases and controls or predictors of suicidal behavior in big-data analyses based on claims data or electronic medical records,” Oquendo added. “It would help to harness large cohorts with genomic and biologic data to study suicide and facilitate development of a registry to more accurately estimate the number of suicide attempters in specific cohorts to inform policy and prevention strategies.”

She was joined at the session by Igor Galynker, M.D., Ph.D., a professor of psychiatry at the Icahn School of Medicine at Mount Sinai, who outlined a proposal to include criteria for suicidal crisis syndrome in DSM. Thomas Joiner, Ph.D., a professor of psychology at Florida State University, outlined the case for creating the diagnosis of acute suicidal affective disorder. Both proposed diagnoses would be distinct from suicidal behavior disorder; they describe a discrete, highly acute, and extremely high-risk pre-suicidal mental state.

“The core feature of the suicidal crisis syndrome is the persistent and desperate feeling of ‘frantic hopelessness’ or entrapment, expressed as an urgency to escape or avoid an unbearable life situation when escape is perceived as impossible,” Galynker said.

Additionally, the syndrome involves affective disturbance, hyperarousal, loss of cognitive control, and social withdrawal. Typical situations that may trigger such a high-risk mental state include terminal illness, humiliating failure at work, or rejection by a romantic partner, Galynker said. ■