# DSM5 Workgroup Examines Proposed Separate Diagnosis for Suicide Disorder



## David Baxter PhD (Apr 27, 2011)

*DSM Workgroup Examines Proposed Separate Diagnosis for Suicide Disorder*
By: M. ALEXANDER OTTO, _Clinical Psychiatry News_
April 27, 2011

A standalone diagnosis of suicidal behavior disorder is being considered for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) to increase the manual?s emphasis on suicide prevention, according to Dr. Jan Fawcett, chairman of the DSM-5 Mood Disorders Work Group. 

The current version, DSM-IV, includes suicide only as a manifestation of major depressive episodes and bipolar disorder, which is problematic for several reasons. 

First, although those diagnoses persist in a patient?s psychiatric history, the fact that they attempted suicide frequently gets lost in the shuffle, even though past attempts significantly increase the risk for future attempts, Dr. Fawcett said. 

Psychiatric patients often are not even asked whether they have attempted suicide, and might not be treated any differently if they have, he said (_Am. J. Psychiatry_ 2002;159:1746-51). 

Also, the risk of suicide "clearly goes across diagnoses. It?s more common in mood disorders, fairly high in borderline disorder, but also high in schizophrenia and elevated in anxiety disorders," as well as substance and alcohol abuse disorders, said Dr. Fawcett, a psychiatry professor at the University of New Mexico, Albuquerque. 

His group believes that a standalone suicidal behavior disorder (SBD) diagnosis would address those problems by encouraging clinicians to ask about past attempts and address risk factors. 

"The idea is to make clinicians more aware of recording these things and factoring them into [their] assessment of the patient. We are trying to get beyond ?no SI? [suicidal ideation] or ?no plan? as a suicide assessment," Dr. Fawcett said. 

There?s a need for that. Most people who see their therapists the day they kill themselves never admit to suicidal ideation, he said (_Br. J. Psychiatry_ 1998;173:531-5). 

The diagnosis also would likely increase research into the problem, "which is sorely needed," he said. 

The proposed criteria include one or more attempts within 12 months that did not occur during a state of active delirium or confusion and did not meet the criteria for cutting or other nonsuicidal self-injury. 

The 12-month limit is suggested because the risk of subsequent attempts is greatest within a year of the first, but also because the group wants to ensure that the stigma of the diagnosis doesn?t "follow [patients] forever," Dr. Fawcett said. 

Feedback from clinicians familiar with the idea has been generally positive, he noted. 

His group also is working on a list of suicide risk factors for possible inclusion in DSM-5, which might include, in addition to past attempts, clinical worsening, a recent loss, acute severe anxiety, family history of suicide, insomnia, alcohol abuse, hopelessness, and impulsivity, among others. 

They "have been shown in various studies to be related to acute suicide in anywhere from weeks to a year after observation. [They] need to be considered in our evaluations of patients" and addressed, he said. 

A 5-point anxiety-severity scale is being considered for mood disorder diagnoses, as well, since anxiety has been shown to increase the risk of suicide (_Depress. Anxiety_ 2009;26:752-7 and _Arch. Gen. Psychiatry_ 2005;62:1249-57). 

It?s too early to tell which of the various proposals will make it into the fifth edition, due out from the American Psychiatric Association in May 2013. 

Clinicians involved in the revision are reviewing the proposals, which may undergo additional refinement. 

"A new diagnosis has a very high threshold of evidence," both clinical and biological, Dr. Fawcett noted. 

He said he has no disclosures.


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## David Baxter PhD (Apr 27, 2011)

Is this really necessary? Increasingly, I get the impression that the DSM5 Committee is flailing blindly in the dark trying to find the light switch.


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## forgetmenot (Apr 27, 2011)

"The idea is to make clinicians more aware of recording these things and factoring them into [their] assessment of the patient. We are trying to get beyond ‘no SI’ [suicidal ideation] or ‘no plan’ as a suicide assessment," Dr. Fawcett said.

Whatever it takes to get the professionals to see and hear   their paitents cry for help   making them more aware can be a good thing.


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## Dragonfly (Apr 27, 2011)

David Baxter said:


> *DSM Workgroup Examines Proposed Separate Diagnosis for Suicide Disorder*
> By: M. ALEXANDER OTTO, _Clinical Psychiatry News_
> April 27, 2011
> His group believes that a standalone suicidal behavior disorder (SBD) diagnosis would address those problems by encouraging clinicians to ask about past attempts and address risk factors.


 
Huh???  I am missing something .... because (of the potential catastrophic consequences and, arguably the human suffering inherent) it is crucial that clinicians evaluate the potential for completing suicide.  But it has apparently been shown that we don't do a very good job of this.  So, a major DSM-V workgroup is considering a new diagnosis - so that clinicians get better evaluating for the potential for completing suicide?!!  This makes no sense to me.

- it (smacks) of creating a new diagnostic entity for billing / reimbursement purposes (if it is a diagnosis that is recognized in the DSM, it can be billed for ....)

- how about the APA (psychiatric, not psychological association) task the Education committee with how to impress this crucial issue on clinicians - both those currently in training and those who are in practice?  It could be done in conjunction with the Psychiatry and the Law committee - in case the issue of potential malpractice might be the determining factor that (finally) gets a clinician's attention.  How about free on-line training on how to evaluate this issue in a longitudinal way - both for inpatient and outpatients.  And how about some education on the evaluation for this issue for clinicians who work with those who are chronically suicidal - but may become acutely potentially more dangerous to themselves?  Wouldn't / shouldn't these pieces address the puported need as outlined by Dr. Fawcett?

My conundrum with the entire DSM-saga has to do with the nebulous area of diagnostic criteria for behaviours ....  and the given that our norms for behaviour change over time (thankfully in some cases).  But it just seems like a conflict of interest to me, to have the APA (psychiatric) as the driving force behind each iteration of the DSM - which then serves as the largest single source of income for the organization.  (ie more money than the annual dues from members).  Which then allows the organization, in part, to effectively lobby for (whatever).  And allows the organization to say when a new DSM will come out.  Which will then generate more monies for the organization.


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