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The Suicidal Crisis


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Table of Contents

1. Introduction a. Our inability to predict imminent suicide b. Long-term and imminent suicide risk c. Lack of instruments for suicide prediction d. Clinical approach to imminent risk assessment e. Multimodal assessments f. One-informant vs. Multi-informant assessments g. How to use the Clinical Guide A roadmap for comprehensive assessment 2. Chapter One: Psychological Models of Suicide a. Introduction b. Historical Perspective c. Shneidman's Theory of Psychache d. Suicide as Escape from Self e. Suicide Crisis Syndrome (SCS) and the Positive Feedback Model of Suicide f. The Cry of Pain/Arrested flight Models g. Cognitive Vulnerability Model h. Fluid Vulnerability Model i. Beck's Diathesis-Stress Model j. Mann's Stress-Diathesis Model k. Joiner's Interpersonal Model l. O'Connor's Integrative Motivational-Volitional Model m. Summary 3. Chapter Two: The Narrative-Crisis Model of Suicide a. Introduction i. Trait vs. State risk factors ii. Static vs. dynamic risk factors b. The Narrative-Crisis Model Overview c. The Trait Vulnerability Component d. The Narrative Component e. The Crisis Component f. Model Flexibility i. Narrative-Driven vs. Crisis-Driven Suicides g. Conclusion 4. Chapter Three: Trait Vulnerability Assessment a. Demographics i. Age, Race, and Ethnicity ii. Gender iii. LGBT b. History of Mental Illness and Suicide Attempts i. History of Mental Illness ii. History of Suicide Attempts c. Childhood History i. Childhood Trauma ii. Parenting Style iii. Attachment Style d. Traits i. Impulsivity ii. Hopelessness and Pessimism iii. Perfectionism iv. Fearlessness and Pain Insensitivity e. Cultural Acceptability i. Cultural Attitudes and Immigration ii. Immigration Status iii. Moral, Philosophical, and Religious Objections iv. Regional Affiliation v. Suicide in the Family vi. Suicide Clusters vii. Suicide Exposure and Practicing f. Case Examples g. Test Cases 5. Chapter Four: Stressful Life Events a. Introduction b. Work and Career i. Economic Hardship ii. Business or Work Failure iii. Loss of Home c. Relationship Conflict i. Romantic Rejection ii. Intimate Relationship Conflict iii. Parents in Conflict with Children iv. Children in Conflict with Parents v. Ongoing Childhood and Adolescent Abuse and Neglect vi. Bullying d. Serious Medical Illness i. Recent Diagnosis ii. Prolonged and Debilitating Illness iii. Acute and Chronic Pain e. Serious Mental Illness i. Recent Diagnosis ii. Recent Hospitalization iii. Recent Suicide Attempts iv. Attempt Lethality v. Exacerbation and Acute Episodes vi. Medication Changes; Initiation, Discontinuation, or Non-compliance f. Recent Substance Misuse i. Drug and Alcohol Use Disorder ii. Acute Alcohol Intoxication and Recent Drug Use iii. Drug or Alcohol Withdrawal 6. Chapter Five: Suicidal Narrative a. Introduction: The Seven Phases of the Suicidal Narrative b. Phase 1: Unrealistic Life Goals c. Phase 2: Entitlement to Happiness d. Phase 3: Failure to redirect to more realistic goals e. Phase 4: Humiliating personal or social defeat f. Phase 5: Perceived burdensomeness g. Phase 6: Thwarted belongingness h. Phase 7: Perception of no future i. Constructing the Suicidal Narrative j. Case Examples k. Test Cases 7. Chapter Six: Suicidal Crisis a. Chronic Suicide Risk vs. Suicide Crisis b. Suicide Warning Signs c. Suicide Crisis Syndrome i. Entrapment ii. Ruminative Flooding iii. Panic-Dissociation iv. Emotional Pain v. Fear of Dying d. Suicidal Ideation and Intent e. Entrapment i. Desperation f. Affective Disturbance i. Emotional Pain ii. Depressive Turmoil iii. Panic-Dissociation 1. Frantic Anxiety 2. Fear of Dying iv. Anhedonia g. Loss of Cognitive Control i. Ruminations ii. Cognitive Rigidity iii. Thought Suppression iv. Ruminative Flooding h. Agitation and Insomnia i. Suicidal Crisis Assessment Algorithm j. Case Examples k. Test Cases 8. Chapter Seven: Emotional Response a. Emotional response as a diagnostic tool b. Emotional Differentiation c. Mindfulness d. From rescue fantasy to helplessness and anger e. Countertransference Love f. Countertransference Hate g. Psychological Defenses: i. Reaction formation ii. Repression iii. Turning against the self iv. Projection v. Denial vi. Rationalization h. Assessing emotional response to the suicidal patient i. Case examples j. The effect our feelings have on suicidal patients 9. Chapter Eight: Conducting Short-Term Risk Assessment Interviews a. Comprehensive Short-Term Risk Assessment Outline b. Suicidal Ideation and Intent: Self-report and its Limitations c. Suicide Risk Assessment Instruments i. SAD PERSON scales ii. The Modular Assessment of Risk for Imminent Suicide (MARIS) d. Assessment Interview Strategies i. Comprehensive Interviews ii. MARIS Interview iii. Expanded MARIS interview e. The Case of Eerie Calm 10. Chapter Nine: Interventions a. Introduction b. Medications and Biological Interventions i. Clozapine ii. Lithium iii. Ketamine c. Psychosocial Interventions i. Dialectical Behavior Therapy (DBT) ii. Cognitive Behavioral Therapy for Suicidal Patients (CBT-SP) iii. Collaborative Assessment and Management of Suicidality (CAMS) iv. Attachment Based Family Therapy (ABFT) v. Safety Planning Interventions d. Alternative and Apps/Internet Intervention i. Mindfulness Meditation ii. Apps and Internet Tools e. Missing the bigger picture i. Risk Assessment and self-care f. Summary 11. Conclusion: Being Vigilant References

About the Author

Dr. Igor I. Galynker is a clinical and research psychiatrist with broad interests in suicide prevention, bipolar disorder, behavioral addictions, and the role of family in psychiatric illness. He has published on these topics in professional journals and in the lay press and has authored a book on family involvement in psychiatric treatment. The Suicidal Crisis, Clinical Guide to the Assessment of Imminent Suicide Risk is the culmination of his work on pre-suicidal affective states and short-term suicide risk.

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