The Suicidal Crisis: Clinical Guide to the Assessment of Imminent Suicide Risk

345 Pages·2017·1.799 MB·English

by  Galynker, Igor, Dr

The Suicidal Crisis

The Suicidal Crisis
Clinical Guide to the Assessment
of Imminent Suicide Risk
Igor Galynker, MD, PhD
Professor of Psychiatry, the Icahn School of Medicine
at Mount Sinai, New York, NY 10029, USA
Director of Research, Department of Psychiatry at
Mount Sinai Beth Israel, New York, NY 10003, USA
Director of the Richard and Cynthia Zirinsky Center
for Bipolar Disorder, Mount Sinai Beth Israel,
New York, NY 10003, USA
Director, Suicide Research Laboratory,
Mount Sinai Beth Israel, New York, NY 10003, USA
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To Cynthia Zirinsky.

Contents
Foreword xiii
Acknowledgments xv
Introduction 1
Our Inability to Predict Imminent Suicide 1
Long- Term and Imminent Suicide Risk 2
Lack of Tests for Suicide Prediction 3
Clinical Approach to the Assessment of Imminent Risk 4
Multimodal Assessments 5
One- Informant Versus Multi- Informant Assessments 6
How to Use The Suicidal Crisis 8
A Roadmap for Comprehensive Assessment 9
1. Psychological Models of Suicide 10
Introduction 10
Historical Perspective 11
Shneidman’s Theory of Psychache 11
Suicide as Escape from Self 13
The Suicide crisis syndrome 13
The Cry of Pain/ Arrested Flight Model 15
Cognitive Vulnerability Model 17
Fluid Vulnerability Model 18
Beck’s Diathesis– Stress Model 19
Mann’s Stress– Diathesis Model 21
Joiner’s Interpersonal Model 22
O’Connor’s Integrated Motivational– Volitional Model of Suicide 24
Summary 26
2. The Comprehensive Narrative-Crisis Model of Suicide 28
Introduction 28
Trait Versus State Risk Factors 28
Static Versus Dynamic Risk Factors 29
Overview of the Narrative-Crisis Model 29
The Trait Vulnerability Component 30
The Suicidal Narrative Component 31
The Suicidal Crisis Component 32
Narrative-Crisis Model Flexibility 33
Narrative- Driven Versus Crisis- Driven Suicidal Behaviors 33
Summary 33
vii
3. Trait Vulnerability Assessment 36
Demographics 36
Age, Race, and Ethnicity 36
Gender 37
Lesbian, Gay, Bisexual, and Transgender 38
History of Mental Illness and Suicide Attempts 38
History of Mental Illness 38
History of Suicide Attempts 40
Childhood History 40
Childhood Trauma 40
Parenting Style (Parental Bonding) 41
Attachment Style 42
Traits 43
Impulsivity 43
Hopelessness and Pessimism 43
Perfectionism 43
Trait Fearlessness and Pain Insensitivity 44
Cultural Acceptability 44
Cultural Attitudes and Immigration 44
Immigration Status 45
Moral, Philosophical, and Religious Objections 45
Regional Affiliation 46
Suicide in the Family 46
Suicide Clusters 47
Suicide Exposure and Practicing 48
Case Examples 49
Test Case 58
4. Stressful Life Events 61
Introduction 61
Work and Career 62
Economic Hardship 62
Business or Work Failure 63
Loss of Home 63
Relationship Conflict 65
Romantic Rejection 65
Intimate Relationship Conflict 66
Parents in Conflict with Children 67
Children in Conflict with Parents 68
Ongoing Childhood and Adolescent Abuse and Neglect 70
Bullying 72
Serious Medical Illness 74
Recent Diagnosis 74
Prolonged and Debilitating Illness 75
Acute and Chronic Pain 77
viii Contents
Serious Mental Illness 78
Recent Diagnosis 78
Recent Hospitalization 79
Recent Suicide Attempts 82
Attempt Lethality 84
Exacerbation and Acute Episodes 86
Medication Changes 87
Recent Substance Misuse 90
Drug and Alcohol Use Disorder 90
Acute Alcohol Intoxication and Recent Drug Use 91
Drug or Alcohol Withdrawal 93
5. Suicidal Narrative 96
The Seven Phases of the Suicidal Narrative 96
Phase 1: Unrealistic Life Goals 98
Phase 2: Entitlement to Happiness 102
Phase 3: Failure to Redirect to More Realistic Goals 106
Phase 4: Humiliating Personal or Social Defeat 109
Phase 5: Perceived Burdensomeness 112
Phase 6: Thwarted Belongingness 115
Phase 7: Perception of No Future 119
Constructing the Suicidal Narrative 121
Probing the Suicidal Narrative: An Interview Algorithm 124
Case Examples 126
Test Case 136
6. Suicide Crisis Syndrome 141
Chronic Long- Term Suicide Risk Versus Acute Short-T erm Suicide Risk 141
Suicide Warning Signs 141
Suicide Crisis Syndrome 143
Suicidal Ideation and Intent 144
Suicidal Ideation 145
Suicide Intent and Plan 145
Entrapment 150
Desperation 151
Affective Disturbance 154
Emotional Pain 155
Depressive Turmoil 155
Extreme (Frantic) Anxiety 156
Fear of Dying 157
Panic–Dissociation 158
Acute Anhedonia 159
Loss of Cognitive Control 164
Ruminations 165
Cognitive Rigidity 165
Thought Suppression 166
Contents ix