Is the act of suicide preceded by a signaling of distress? Do people who contemplate suicide somehow share it with us, directly or indirectly? Are they aware of many of the dynamics that drive them to this fateful decision?
The fact is that nine out of ten failed suicides regret having tried. They regain the joie de vivre, the joy of life, and they commit themselves to never try again.
There is a small minority of serial suiciders, people who try again and again and again until, unfortunately, they succeed. But that's a really, really tiny minority.
For the vast majority of people who have had a suicide experience or suicide attempt in their history it's a single one.
So what do we know about the warning signs, the red, the toxins and signals?
This is the topic of today's video.
My name is Sam Vaknin. I'm the author of Malignant Self-Love, Narcissism Revisited, and I'm a professor of clinical psychology.
Many senior scholars, many psychologists and clinicians are calling for the inclusion of a new diagnosis, a new condition in the sixth edition of the Diagnostic and Statistical Manual and in the next edition of the ICD, the International Classification of Diseases.
This new condition is dubbed suicide crisis syndrome, SCS. And it relies on a body of studies and theories which are collectively known as the narrative crisis model.
I will deal with both in today's video.
Dr. Igal Glicker is a clinical professor of psychiatry and director of the Mount Sinai Suicide Prevention Research Lab in New York City. He is a harsh critic of the medical community's approach to suicide prevention. He thinks psychologists are doing even worse.
Together with a few colleagues all over the world, Glicker is proposing to validate the use of suicide crisis syndrome as a diagnosis. And he believes that should this be recognized as a clinical entity, as a condition, it would reduce imminent suicide risk and allow us to evaluate it and treat it much more efficaciously.
Now these are very big claims.
Suicide had been studied at least since the 17th century and we didn't exactly get better at preventing it.
Suicide above all is a statement, it's a signal. It's exactly like using language. And so it's a kind of free speech act.
The person who is committing suicide is actually informing us that life is not worth living anymore, that he does not see or she does not see any improvement in the future. There's no vision of things getting better.
It's a choice of pessimism over optimism, but it is a choice.
And this is where the philosophy of suicide, the philosophy of the study of suicide, becomes convoluted because we believe in free choice and we believe in free speech and suicide is both.
And yet, as I said at the beginning of this video, the vast majority of people who have ever attempted suicide lived to regret it bitterly.
They think they've done the wrong thing. They think they've been motivated by unconscious and conscious forces which were beyond their control. They are aghast and befuddled by their own choices, especially the choice, to terminate their life.
Suicide Crisis Syndrome is a negative, cognitive and affective state. It is associated with imminent suicidal behavior, and it therefore denotes people with a high risk for suicide.
What Glicker and his colleagues, again, all over the world, it's a loose coalition, loose network, what they want to do is they want the Diagnostic manual committee to recognize that suicide is not a one-time event isolated from anything that came before it or in majority of cases after it.
They think suicide is integrated in a much larger map of mental wellness or mental illness. And therefore, they think that there is such a thing as SCS.
There is such a thing as a syndrome of behaviors, effects, thoughts, cognitions, and signaling which put together could tell us with great certainty when someone is about to commit the atrocious and uncommissible act and actually, to be honest, the stupid act of terminating one's life.
And so these people, these scholars, believe that we should have a suicide specific diagnosis. We should not consider suicide as a behavior that or a choice that is attendant upon other mental illnesses. Kind of a second thought or byproduct.
They don't believe in this. They believe that suicide is its own mental health condition, unrelated to others.
And so they demand to include it in the diagnostic manuals.
Clinicians depend crucially on self-reporting when someone is depressed, when someone is anxious, when someone is psychotic, when someone is paranoid to the extreme, mental health practitioners and clinicians interview them. They interview them and they ask them, are you contemplating suicide? Are you imagining suicide? Do you consider committing suicide? Did you take any steps towards realizing this goal?
So it all relies crucially. The diagnosis, the treatment, everything, the evaluation, they all rely crucially and exclusively, actually, on self-reporting.
How do you feel?
I am a great opponent of self-reporting in psychological tests, in psychological evaluations, and generally in psychology.
I think relying on self-reporting is a very self-defeating, not to mention inane or dumb strategy.
When we ask narcissists to self-report in the various tests for narcissistic personality disorder, when we ask psychopaths to essentially diagnose themselves by telling the truth about their motivations, their emotions, their cognitions, their history, we are shooting ourselves in the collective foot.
Self-reporting should be outlawed, criminalized in psychology. It should be eliminated. It's really, really, really bad idea.
And so people who are on the verge of committing suicide, on the precipice, these people are in acute pain. They're in distress.
Their answers are inaccurate or self-deceiving or completely befogged, completely submerged in extreme cognitive distortions and biases.
You cannot approach someone who is thinking about dying and have a reasonable, rational conversation with them. You cannot expect them to introspect and self-observe and provide you with accurate objective data.
This is ridiculous.
Galanter says suicide is the most lethal psychiatric, I'm quoting him, suicide is the most lethal psychiatric condition because people die from it.
And yet he says, we rely on people at the worst moment of their lives to tell us accurately when and how they're going to kill themselves.
We don't ask people with serious mental illness to diagnose their own mental illness and then rely on the diagnosis, he says.
The fact is that most people who attempt or die by suicide actually do not have suicidal ideation.
Now, I know this comes as a shock to you, and many of you are going to dispute this sentence. You're going to say, Sam Vaknin, you are wrong again. That's not true. All suicides are preceded by suicidal ideation. All suicidal attempts follow suicidal thoughts.
And yet this is not true. It's a myth. It's a myth propagated by self-styled experts online yet again. That is a myth.
Data across multiple studies over multiple decades and meta-analysis demonstrate conclusively that people who attempt suicide and people who commit suicide did not have or do not have suicidal thoughts or suicide ideation in the period preceding the attempted suicide or in the period preceding the actual suicide.
When healthcare providers, clinicians, family members approach these people, they don't talk about suicide, they actually sometimes are very optimistic. They have plans. They make moves. They don't look like they're about to commit suicide.
When we administer questionnaires and scales to people who are at suicide risk, for example, depressed people or prisoners, we don't see any hint of suicidal ideation.
I could generalize and say that suicidal ideation is more or less a myth, more or less an invention. A fantasy of psychologists maybe. They want to believe in some orderly procession or progression from ideation to action.
But that is not the case. That's not true.
That is not to say that people don't have or entertain suicidal ideation. Of course they do.
For example, people with borderline personality disorder have a lot of suicide ideation throughout the lifespan. But these people are actually less likely to commit suicide. It's as if the destructive energy went into thinking about suicide rather than actually attempting suicide.
Okay, these are the facts.
So self-reporting may be very misleading. Outside observation and evaluation is often misleading.
Because we see people who go about their normal lives, perform chores and functions to the very last second, make plans, buy air tickets for a vacation, prepare a party, a birthday party, and so on, and then suddenly commit suicide.
So observing people does not tell you if they're about to commit suicide or not.
We need to change our point of view. We need to become evidence-based rather than fantasy-based.
Patients at acute risk of suicide are assessed and they are treated wrongly. We try to prevent suicide by gauging them according to our point of view.
We say to ourselves, had I wanted to commit suicide, had I contemplated suicide, this is how I would have behaved.
But that's a wrong way to go about it.
Consequently, we miss many opportunities to intervene.
But Galenker and his allies are pretty optimistic.
They say that SCS is the final and most acute stage of what they call the narrative crisis model of suicide. And it reflects a progression of suicidal risk from chronic risk factors to imminent suicidal risk.
In other words, it's a phenomenological approach, not an epistemological one.
The diagnostic approach here is by analyzing risk factors, the way we do, for example, in cardiology.
The narrative crisis model, says Galenker, has four distinct and successive stages, with specific guidance and applicable interventions that enable patients to receive a stage-specific treatment.
This is another myth in suicide.
There is a belief that suicide is a binary state, a black and white condition. You either contemplate suicide and immediately commit suicide or suicide never crosses your mind whatsoever.
That is not true. Suicide is a process, sometimes a multi-annual process, a very long process. And this process has distinct stages. And if we observe these stages, we can predict the next stages, and we can intervene, and we can treat, and we can help.
Galenker says, suicide crisis syndrome is a very treatable syndrome that rapidly resolves with appropriate interventions. Once it is treated, the patient can engage with psychotherapy and other treatments.
Galenker and his colleagues tried this approach. They already tested it and they had pretty encouraging results in various studies.
They also engage with clinicians. They try to somehow evaluate or appraise the clinician's subjective and objective views.
And they use a variety of risk assessment tools to assess suicide ideation in its connection or alleged connection to actual suicide.
And this is a new movement in the study of suicide and the prevention of suicide.
There is a new focus on identifying specific subtypes of individual who are at risk for suicide.
Are you in pain? Are you dissociative? Do you have interoception, the ability to sense and interpret internal signals from your body?
All these are indicators of imminent suicide or looming suicide, or at least a risk of suicide.
Suicide risk factors are well known. We know that certain physical health conditions predisposed to suicide.
Suicide risk factors are well known. We know that certain physical health conditions predisposed to suicide, certain symptoms. We know that borderline personality disorder does. 11% of all people with borderline personality disorder end their lives.
Positive mental health, their identification and available treatments for depression and other common mental health disorders, and the management of suicidal risk or crisis stigma, all these are adjacent activities.
So there's now a focus on environments, environmental focus.
For example, rearranging, redesigning the workplace settings, putting an emphasis on vulnerable groups.
We know that suicides peak. They are at the maximum, among young people, the elderly, the unemployed, migrants, and people affected by mental and physical disorders.
We need to focus on these populations.
So there's an upheaval in the study and prevention of suicide.
And I would like to read to you sections from two seminal articles, recent articles, regarding this topic.
The first article is titled The Comprehensive Narrative Crisis Model of Suicide. The author is Jessica Briggs. And you can find, of course, the articles in the literature, in the description of this video, the literature section.
So here's the abstract of what she says.
She says, the narrative crisis model of suicide posits that individuals attempt suicide when they experience distinct emotional state termed the suicide crisis syndrome.
This chapter describes the model which has three components, trait vulnerability, suicidal narrative, and the suicidal crisis syndrome.
Trait vulnerability includes all static risk factors, which are relatively stable over time and distal to acute suicidal behavior.
Suicidal narrative describes a suicidal person's perception of his or her life story, in which the past has led to an intolerable present and a future that is unimaginable.
The suicidal crisis syndrome is a distinct emotional state characterized by entrapment, affective dysregulation and loss of cognitive control.
The result is a suicidal act, brought on by an emotional urge to end the intolerable mental pain of the syndrome.
Imminent suicide risk is primarily decided or determined by SCS intensity, to which both trait vulnerability and the suicidal narrative also contributed independently.
And this is published in a book called The Suicidal Risk, Clinical Guide to the Assessment of Imminent Suicide Risk, edited by the aforementioned Ego Galinker.
Highly recommended for practitioners and clinicians who deal with suicide on a regular basis, for example, therapies of borderline personality disorder.
I'm going to read to you something that Ego Galinker himself has written together with others Sarah Bloch-Elkon, Lisa Cohen.
And I'm going to read to you what he has written about the suicide crisis syndrome.
The article is titled Suicide Crisis Syndrome, a specific diagnosis to aid suicide prevention, was published in September this year.
So these are recent studies.
He says suicide is a global public health issue, claiming over 700,000 lives annually worldwide. Opportunities for intervention are ample, as half of suicide decedents contacted a healthcare professional within a month of their deaths.
So there has been previous contact.
In these encounters, says Gallenker, suicide risk assessments are based on patients' self-report or suicidal intent and chronic risk factors such as past attempts and prior psychiatric diagnosis.
And yet, he says, up to 75% of those dying by suicide explicitly denied suicidal intent at their last meeting with a health professional.
Almost 20% of suicide attempters do not have a diagnosable mental disorder.
Moreover, traditional risk factors such as previous suicide attempts and a history of mental illness do not reliably predict short-term suicide risk.
You've heard all this?
Contra to intuition, contra to myths, contra to misconceptions and the misinformationthat is very prevalent online, unfortunately.
Gallenker continues.
Over the last decade, several independent research teams have documented the existence of specific acute mental states associated with emergence of suicidal behavior.
However, neither the DSM nor the ICD ever carried a diagnosis referring to these states.
The suicide crisis syndrome, SCS, aims to fill this gap in psychiatric nosology and is under review for inclusion in the DSM.
This diagnosis provides a systematic tool for recognizing and treating a mental disorder, presenting imminent suicide risk, without relying on self-reported suicidal intent.
SCS is the last and most acute stage of the narrative crisis model of suicide, which reflects the progression of suicidal risk from chronic risk factors to imminent suicidal risk and provides a comprehensive framework for the design and implementation of treatments that specifically target each of the four stages in the suicidal process.
The empirically driven SCS criteria have evolved over a period of 15 years. They incorporate five empirically validated domains, which together constitute a unidimensional syndrome.
Suicidal ideation is not included, due to its demonstrated unreliability as an indicator of imminent suicidal behavior.
The first CSS domain, Criterion A, features a persistent and intense feeling of frantic helplessness and hopelessness, in which the individual feels trapped in a situation experience both as intolerable and inescapable.
Criterion B includes four distinct symptom dimensions.
B1, affective disturbance.
B2, loss of cognitive control.
B3, hyperarousal.
And B4, social withdrawal.
B1, affective disturbance may manifest through emotional pain, depressive turmoil, extreme anxiety with unusual physical sensations, and acute anhedonia.
B2 involves loss of cognitive control, ruminations, cognitive rigidity, failed thought suppression, and ruminative flooding, loss of control over thoughts accompanied by headaches and head pressure.
B3, hyperarousal involves agitation, restlessness, hypervigilance and intense and exaggerated responsiveness to sensory inputs, irritability and insomnia.
And finally, B4, social withdrawal involves avoidance of social engagements and evasive communication with others.
To be diagnosed with SCS, patients must meet criterion A and have at least one symptom from each of criteria B1 to B4.
Several SCS assessment instruments have been developed for use among diverse populations.
And then he goes in the article into the various instruments they have developed.
He continues to say, SCS demonstrated excellent internal consistency within and across five symptom dimensions in United States and international samples.
Several US studies, as well as those conducted in India, Korea, Taiwan, Russia and Brazil, further supported the unidimensionality and five-factor structure of SCS.
To date, over 15 studies have demonstrated the predictive validity of SCS for imminent suicidal ideation, preparatory actions and suicidal attempts.
And then he goes on and on to analyze the utility of the syndrome in the hands of clinicians, especially frontline clinicians, the one who cope with imminent suicide risk and suicide attempts.
And he analyzes the psychometric strength of SES, various dissemination efforts of SES tools, and so on and so forth.
He ends by saying that a DSM and possibly ICD diagnosis of SCS with an assigned diagnostic code would provide clinicians with a systematic means for assessing and reducing imminent suicide risk, even in high-risk individuals who deny suicidal ideation and intent, while distinguishing patients with self-reported suicidal ideation at little risk of suicidal behavior.
Furthermore, says Gallinker, the conceptual and operational clarity of the syndrome would likely decrease clinicians' anxiety about working with suicidal patients, in turn, promoting the development of an effective therapeutic alliance.
Lastly, we believe that the increased clarity of suicide risk assessment, using DSM-based SCS diagnosis, would reduce legal challenges, promote education, and stimulate research for new treatments, all necessary to enhance and maximize suicide prevention.
The comprehensive narrative crisis model of suicide, now that's me, end quote.
What I have to say is that the comprehensive narrative crisis model of suicide, coupled with the suicide crisis syndrome as a clinical entity, it's the first time that I see something in the literature that focuses on evidence, on reality, on actual observables, rather than on myths, fiction, self-reporting and other such nonsense.
This is the first time that I see a real opportunity to increase the efficacy of the treatment and prevention of suicide.
It's a very hopeful theoretical development which can and should be translated into diagnostic tools and into therapy, highly specific type of therapy, suicide prevention therapy.
So I'm very optimistic about the future of this field and I think this narrative crisis model and the suicide crisis syndrome is the future of the field.
I think this is going to become the orthodoxy and the mainstream within a few years. At least, I hope so.