Igor Galynker, MD, returns to the Psychcast, this time to discuss his most recent work on suicidal crisis syndrome with host Lorenzo Norris, MD.

Dr. Galynker is professor of psychiatry and director of the Galynker 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 disclosures.

Take-home points

• 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 countries.
• 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 withdrawal.
• 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.

Summary

• In SCS, the two primary factors are a sense of entrapment and cognitive rigidity followed by insomnia or agitation and social withdrawal.
• 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 anxiety.
• 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 risk.
• 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 assessment.

References

Cohen LJ et al. Suicide Life Threat Behav. 2019 Apr;49(2):413-22.

Hawes M et al. Compr Psychiatry. 2017 Jan;72:88-96.

Galynker I et al. Depress Anxiety. 2017 Feb;34(2):147-58.

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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