David Baxter PhD
Late Founder
DSM Workgroup Examines Proposed Separate Diagnosis for Suicide Disorder
By: M. ALEXANDER OTTO, Clinical Psychiatry News
April 27, 2011
A standalone diagnosis of suicidal behavior disorder is being considered for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) to increase the manual?s emphasis on suicide prevention, according to Dr. Jan Fawcett, chairman of the DSM-5 Mood Disorders Work Group.
The current version, DSM-IV, includes suicide only as a manifestation of major depressive episodes and bipolar disorder, which is problematic for several reasons.
First, although those diagnoses persist in a patient?s psychiatric history, the fact that they attempted suicide frequently gets lost in the shuffle, even though past attempts significantly increase the risk for future attempts, Dr. Fawcett said.
Psychiatric patients often are not even asked whether they have attempted suicide, and might not be treated any differently if they have, he said (Am. J. Psychiatry 2002;159:1746-51).
Also, the risk of suicide "clearly goes across diagnoses. It?s more common in mood disorders, fairly high in borderline disorder, but also high in schizophrenia and elevated in anxiety disorders," as well as substance and alcohol abuse disorders, said Dr. Fawcett, a psychiatry professor at the University of New Mexico, Albuquerque.
His group believes that a standalone suicidal behavior disorder (SBD) diagnosis would address those problems by encouraging clinicians to ask about past attempts and address risk factors.
"The idea is to make clinicians more aware of recording these things and factoring them into [their] assessment of the patient. We are trying to get beyond ?no SI? [suicidal ideation] or ?no plan? as a suicide assessment," Dr. Fawcett said.
There?s a need for that. Most people who see their therapists the day they kill themselves never admit to suicidal ideation, he said (Br. J. Psychiatry 1998;173:531-5).
The diagnosis also would likely increase research into the problem, "which is sorely needed," he said.
The proposed criteria include one or more attempts within 12 months that did not occur during a state of active delirium or confusion and did not meet the criteria for cutting or other nonsuicidal self-injury.
The 12-month limit is suggested because the risk of subsequent attempts is greatest within a year of the first, but also because the group wants to ensure that the stigma of the diagnosis doesn?t "follow [patients] forever," Dr. Fawcett said.
Feedback from clinicians familiar with the idea has been generally positive, he noted.
His group also is working on a list of suicide risk factors for possible inclusion in DSM-5, which might include, in addition to past attempts, clinical worsening, a recent loss, acute severe anxiety, family history of suicide, insomnia, alcohol abuse, hopelessness, and impulsivity, among others.
They "have been shown in various studies to be related to acute suicide in anywhere from weeks to a year after observation. [They] need to be considered in our evaluations of patients" and addressed, he said.
A 5-point anxiety-severity scale is being considered for mood disorder diagnoses, as well, since anxiety has been shown to increase the risk of suicide (Depress. Anxiety 2009;26:752-7 and Arch. Gen. Psychiatry 2005;62:1249-57).
It?s too early to tell which of the various proposals will make it into the fifth edition, due out from the American Psychiatric Association in May 2013.
Clinicians involved in the revision are reviewing the proposals, which may undergo additional refinement.
"A new diagnosis has a very high threshold of evidence," both clinical and biological, Dr. Fawcett noted.
He said he has no disclosures.
By: M. ALEXANDER OTTO, Clinical Psychiatry News
April 27, 2011
A standalone diagnosis of suicidal behavior disorder is being considered for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) to increase the manual?s emphasis on suicide prevention, according to Dr. Jan Fawcett, chairman of the DSM-5 Mood Disorders Work Group.
The current version, DSM-IV, includes suicide only as a manifestation of major depressive episodes and bipolar disorder, which is problematic for several reasons.
First, although those diagnoses persist in a patient?s psychiatric history, the fact that they attempted suicide frequently gets lost in the shuffle, even though past attempts significantly increase the risk for future attempts, Dr. Fawcett said.
Psychiatric patients often are not even asked whether they have attempted suicide, and might not be treated any differently if they have, he said (Am. J. Psychiatry 2002;159:1746-51).
Also, the risk of suicide "clearly goes across diagnoses. It?s more common in mood disorders, fairly high in borderline disorder, but also high in schizophrenia and elevated in anxiety disorders," as well as substance and alcohol abuse disorders, said Dr. Fawcett, a psychiatry professor at the University of New Mexico, Albuquerque.
His group believes that a standalone suicidal behavior disorder (SBD) diagnosis would address those problems by encouraging clinicians to ask about past attempts and address risk factors.
"The idea is to make clinicians more aware of recording these things and factoring them into [their] assessment of the patient. We are trying to get beyond ?no SI? [suicidal ideation] or ?no plan? as a suicide assessment," Dr. Fawcett said.
There?s a need for that. Most people who see their therapists the day they kill themselves never admit to suicidal ideation, he said (Br. J. Psychiatry 1998;173:531-5).
The diagnosis also would likely increase research into the problem, "which is sorely needed," he said.
The proposed criteria include one or more attempts within 12 months that did not occur during a state of active delirium or confusion and did not meet the criteria for cutting or other nonsuicidal self-injury.
The 12-month limit is suggested because the risk of subsequent attempts is greatest within a year of the first, but also because the group wants to ensure that the stigma of the diagnosis doesn?t "follow [patients] forever," Dr. Fawcett said.
Feedback from clinicians familiar with the idea has been generally positive, he noted.
His group also is working on a list of suicide risk factors for possible inclusion in DSM-5, which might include, in addition to past attempts, clinical worsening, a recent loss, acute severe anxiety, family history of suicide, insomnia, alcohol abuse, hopelessness, and impulsivity, among others.
They "have been shown in various studies to be related to acute suicide in anywhere from weeks to a year after observation. [They] need to be considered in our evaluations of patients" and addressed, he said.
A 5-point anxiety-severity scale is being considered for mood disorder diagnoses, as well, since anxiety has been shown to increase the risk of suicide (Depress. Anxiety 2009;26:752-7 and Arch. Gen. Psychiatry 2005;62:1249-57).
It?s too early to tell which of the various proposals will make it into the fifth edition, due out from the American Psychiatric Association in May 2013.
Clinicians involved in the revision are reviewing the proposals, which may undergo additional refinement.
"A new diagnosis has a very high threshold of evidence," both clinical and biological, Dr. Fawcett noted.
He said he has no disclosures.
