Presenter Renée Binder, MD; Margaret May, MD; Joseph Obegi, PsyD Article contribution by: Diana Wertz, MD
Dr. Renée Binder, Dr. Margaret May, and Dr. Joseph Obegi shared with us their thoughts about suicidality as a diagnosable discrete mental disorder. The session started with Dr. Obegi pointing out that a substantial percentage of suicides do not occur in individuals with an underlying Axis I disorder, and that suicidality is the mental state that occurs prior to suicide. He discussed that diagnosing suicidality would be clinically useful in that it conveys information to providers, helps guide treatment, may clarify features of the patient’s psychiatric condition as well as help providers predict prognosis. The panelists then went on to discuss suicidal behavior disorder (SBD) which is a condition marked for further study in the DSM-5. SBD is primarily defined by the individual having made a suicide attempt in the last 24 months, which members of the panel found limiting in terms of utility. Dr. Obegi suggested that if the SBD diagnosis included information on affective rigidity, cognitive flexibility, the presence or absence of psychological pain and hopelessness, it would ultimately be more informative in terms of patient care.
Dr. Margaret May discussed four different patient cases with four different underlying diagnoses in which suicidality was present. She emphasized the complexity of risk assessment and risk mitigation for any particular individual. The cases she presented illustrated social and cultural factors that influence one’s desire to live, the waxing and waning nature of suicidality based on sporadic factors, issues of secondary gain and that there can be a discrepancy between suicidality in terms of verbal endorsement versus behaviors. Ultimately, Dr. May expressed that she found thorough risk assessment and risk factor mitigation specifically tailored to that unique individual to be more helpful in a clinical setting than a DSM-5 diagnosis of suicidality.
Dr. Binder shared her experience regarding the process of getting a diagnosis into the DSM-5. She explained the diagnosis should be stable, have clinical value as well as validity and reliability. We then discussed that suicide attempts occur in a wide range of psychiatric disorders such as affective disorders, anxiety disorders, adjustment disorders and psychotic disorders. Given the wide variety of conditions associated with suicide, Dr. Binder suggested that certain DSM-5 conditions could have a suicide specifier that would be sufficient to convey clinically useful information, thus obviating the need for a specific suicidal behavior disorder diagnosis. All panelists agreed that risk assessment and an understanding of the underlying symptomatology that drive suicide are helpful clinically.