The necessity, validity, and clinical utility of a new diagnostic entity: Acute suicidal affective disturbance

Abstract

Objective: Here we argue for the necessity, validity, and clinical utility of a new diagnostic entity, acute suicidal affective disturbance (ASAD).Method: We expand on the conceptual, clinical, and practical rationale for ASAD, propose its defining features, describe research results to date, and suggest avenues for future research.Results: There is accruing evidence for the existence of a previously unclassified, rapid-onset mood disturbance that geometrically escalates and regularly results in life-threatening behavior.Conclusions: ASAD research may not only improve the field's understanding of suicidal behavior but also enhance clinical effectiveness and save lives.The first step in wisdom is to know the things themselves… objects are distinguished and known by classifying them methodically and giving them appropriate names. (Carolius Linnaeus).Consider the following scenario, based on actual cases encountered by the senior author: an individual is diagnosed with a nonmood disorder psychiatric condition (e.g., schizophrenia) and admitted to inpatient psychiatry. During hospitalization, mood disorder symptoms and suicide risk are regularly assessed and viewed as minimal. The patient's chart indicated the occurrence of a suicide attempt approximately 4 years before. However, the circumstances surrounding this attempt were not documented, and unbeknownst to unit clinicians and unreported by the patient, a past history of rapidonset, intense suicidal crises occurred about 5 years previously. The condition is aggressively treated and clear improvement is observed. The individual is, thus, discharged; approximately 18 hr postdischarge, suicidality again intensifies dramatically, culminating in the individual's death by suicide. The primary condition had not worsened.

Suicide in DSM-5: Current Evidence for the Proposed Suicide Behavior Disorder and Other Possible Improvements

“…ASAD criteria include four primary features: a drastic, acute increase in suicidal intent, marked social alienation or self-alienation, hopelessness, and over-arousal (i.e., insomnia, irritability, or agitation). Initial research demonstrates ASAD's validity, reliability, and utility ( 150 , 169 ). SCS includes five primary components: entrapment, affective disturbance, loss of cognitive control, hyperarousal, and social withdrawal.…”

Crisis Concept Re-loaded?—The Recently Described Suicide-Specific Syndromes May Help to Better Understand Suicidal Behavior and Assess Imminent Suicide Risk More Effectively

“…Acute Suicidal Affective Disturbance (ASAD) is based on empirical pre-suicidal clinical features and theory-driven predictors ( 13 , 17 , 19 ) ( Table 2 ). This concept emphasizes that symptoms develop very quickly.…”

“…While these are clinically important features, they alone provide little useful information on the background of suicidal behavior (e.g., mental disorder, crisis situation, etc.) and do not help to identify warning signs or acute risk and to predict future suicidal behavior ( 12 , 13 ). Because acute suicide risk usually develops rapidly (up to some days or hours) ( 14 ), it would be necessary to introduce a category that emphasizes the characteristics of this life-threatening pre-suicidal state of mind requiring urgent intervention ( 15 , 16 ).…”

“…However, in recent years, two complex, specific syndromes have been described that may assist in a more accurate assessment of pre-suicidal psychopathology and thus in the prediction of suicidal behavior. Researchers recommended the introduction and—after a predictive validation process—the clinical use of two suicide-specific syndromes, the Acute Suicidal Affective Disturbance (ASAD) ( 13 , 17 ) and Suicidal Crisis Syndrome (SCS) ( 5 , 18 ) ( Table 2 ). These newly described syndromes deserve attention because the well-known, classical theory of suicidal crisis by Caplan and the presuicidal syndrome, described by Ringel (Ringel's Triad), as well as other related phenomena, such as “psychic pain,” “cry-for-help,” or “cry-of-pain” have been already known for decades ( 20 ) ( Table 3 ).…”

Real-Time Monitoring of Suicide Risk among Adolescents: Potential Barriers, Possible Solutions, and Future Directions

“…For example, nearly 70% of adolescents in one retrospective study reported that thoughts of suicide began just 30 min before their most recent suicide attempt (Negron, Piacentini, Graae, Davies, & Shaffer, 1997). Several proposed clinical diagnoses such as the Suicide Crisis Syndrome (Schuck, Calati, Barzilay, Bloch-Elkouby, & Galynker, 2019) and Acute Suicidal Affective Disturbance (Rogers, Chu, & Joiner, 2019) also include aspects of episodic crisis-like states of intense suicidal thinking (in addition to other states, e.g., agitation) appearing imminently before suicidal behavior. Despite the theoretical support, retrospective empirical work, and earlier calls to do so (Glenn & Nock, 2014), there has been no prospective work exploring the minutes and hours right before a suicide attempt.…”