Received: 26 October 2018 Revised: 21 December 2018 Accepted: 22 December 2018

DOI: 10.1002/bsl.2397

SPECIAL ISSUE ARTICLE

Suicide Crisis Syndrome: A review of supporting

evidence for a new suicide‐specific diagnosis

Allison Schuck1 | Raffaella Calati1 | Shira Barzilay2 |

Sarah Bloch‐Elkouby2 | Igor Galynker1,2

1
Department of Psychiatry, Mount Sinai Beth
Israel, New York, NY, USA
2
Icahn School of Medicine at Mount Sinai,
New York, NY, USA
Correspondence
Allison Schuck, Department of Psychiatry,
Mount Sinai Beth Israel, 317 E. 17th St, Suite
5F13, New York, NY 10003, USA.
Email: allison.schuck@mountsinai.org
Suicide is a major public health problem, and suicide rates
are still on the rise. Current strategies for identifying indi-
viduals at risk for suicide, such as the use of a patient's
self‐reported suicidal ideation or evidence of past suicide
attempts, have not been sufficient in reducing suicide rates.
Recently, research groups have been focused on determining
the acute mental state preceding a suicide attempt. The
development of an acute suicidal diagnosis, the Suicide Crisis
Syndrome (SCS), is aimed at capturing this state to better
treat individuals. The SCS has five main evidence‐based
components—entrapment, affective disturbance, loss of cog-
nitive control, hyperarousal, and social withdrawal. The SCS
may provide clinicians with the ability to identify individuals
who are experiencing an acute pre‐suicidal mental state,
regardless of their self‐reported suicidal ideation. Future
research leading to the incorporation of this diagnosis into
clinical practice could improve the quality of care and reduce
the personal, societal, and legal burden of suicide.

1 | I N T RO DU CT I O N

Suicide is a leading cause of death worldwide, and the 10th leading cause of death in the USA (Centers for Disease
Control and Prevention, 2015). Despite increased public attention and ongoing research efforts in suicide prevention,
in the USA suicide rates increased by 30% between 1999 and 2016 (Stone et al., 2018), with nearly 45,000 deaths by
suicide in 2016 (Centers for Disease Control and Prevention, 2016).
A widely accepted tool for assessing suicide risk is self‐reported suicidal ideation. However, there are a variety of
obstacles to this approach. First, as reported by Deisenhammer et al. (2009), explicit suicidal ideation or intent may last
less than 10 min preceding a suicide attempt, which would occur outside the clinical setting and therefore is not useful
for meaningful clinical intervention. Second, while conscious suicidal ideation may or may not precede suicide, only a

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2 SCHUCK ET AL.

minority of suicide decedents reveal it through self‐report. A recent Centers for Disease Control and Prevention (CDC)
report underscored that self‐reported suicidal ideation was present only in a fraction of suicide decedents (Stone et al.,
2018). Of those who died by suicide and had a diagnosed mental health condition, 24.5% expressed suicidal intent. Of
those with no diagnosed mental health condition, 22.4% expressed suicidal intent (Stone et al., 2018). This suggests that
more than 75% of individuals who die by suicide do not express suicidal intent. Thus, this currently accepted strategy for
suicide‐risk identification and prevention is not sufficient, and it is of vital necessity to improve our clinical approach.
Despite the urgent need to predict suicide, there has never been a suicide‐specific diagnosis in the Diagnostic and
statistical manual of mental disorders (DSM; American Psychiatric Association, 2013). Since the DSM is a widely used
tool for diagnosis of mental disorders, and up to 22% of suicide decedents have contact with a mental health profes-
sional within one week of their attempt (Stene‐Larsen & Reneflot, 2017), a suicide‐specific diagnosis could be crucial
in identifying those at risk for imminent suicide.
Two main arguments can be made for the use of a suicide‐specific diagnosis. First, suicide has only been included as
a symptom of other disorders in the DSM. For example, one possible criterion of Major Depressive Disorder is thoughts
of suicide (American Psychiatric Association, 2013), which also appear in other diagnoses such as Bipolar Disorder and
Borderline Personality Disorder. Recommended treatment for those presenting with suicidal thoughts includes treating
the underlying disorder, so suicide may be treated as a symptom of a broader disorder. Second, some individuals do not
meet criteria for any existing mental disorders and still go on to attempt suicide. In fact, in the recent CDC report, more
than half of individuals who died by suicide did not have a psychiatric diagnosis at the time of their death (Stone et al.,
2018). Although many of those who were undiagnosed may have simply not had their disorder properly detected, there
are many individuals who may have met criteria for a suicide‐specific diagnosis. Such a diagnosis may help clinicians
make suicide central to their treatment, and could reduce the personal, legal, and societal burden.
The fifth version of the DSM (DSM‐5; American Psychiatric Association, 2013) includes Suicidal Behavior Dis-
order (SBD) as a “condition for further study,” which marks the first step towards understanding the phenomenol-
ogy, neurobiology, and clinical implications of such a diagnosis. The proposed diagnosis of SBD includes a previous
suicide attempt. Thus, in concordance with much of the suicide research literature, SBD indicates a lifetime risk
and diagnosis rather than a risk for near‐term or imminent suicide (Oquendo & Baca‐Garcia, 2014). Lifetime risk
factors have been informative in identifying those at eventual risk for suicide, but they seem to be distinct from
short‐term risk factors, predictive of an acute pre‐suicidal mental state and of imminent suicide (Cassells, Paterson,
Dowding, & Morrison, 2005).
Recent research has begun to identify psychological processes that occur in the days, hours, and minutes lead-
ing up to a suicide attempt (Bagge, Glenn, & Lee, 2013; Deisenhammer et al., 2009; Galynker, 2017; Rogers et al.,
2017). Bagge et al. (2013) reported acute behavioral and psychological changes within hours preceding suicide
attempts. Further, Deisenhammer et al. (2009) showed that suicidal ideation could be a very late phenomenon
in the suicidal process, appearing within 10 min preceding the suicide attempt. Reflecting these recent research
findings, two acute suicidal diagnoses have been proposed: the Suicide Crisis Syndrome (SCS; Galynker, 2017)
and Acute Suicidal Affective Disturbance (ASAD; Rogers et al., 2017). While there are similarities in some compo-
nents, the SCS is distinct in that suicidal ideation is not required for diagnosis, though it may be present.
The SCS concept was first proposed by Yaseen et al. (2010) using the Suicide Trigger Scale, second version (STS‐
2). This version of the STS was the first to be tested prospectively, and it distinguished two factors of the then‐
termed “suicide trigger state.” The first factor described the loss of cognitive control over one's thoughts and was
termed “ruminative flooding.” The second factor described the affective state of “frantic hopelessness,” similar to
entrapment (Galynker, Yaseen, & Briggs, 2014). In addition to frantic hopelessness and ruminative flooding, the later
expanded version of the scale, the STS‐3, also described a factor of unusual body sensations and dissociation termed
“psychotic somatization” (Yaseen, Gilmer, Modi, Cohen, & Galynker, 2012). The three factor structure of the suicide
trigger state obtained with STS‐3 has been replicated, and high STS‐3 scores among psychiatric inpatient populations
were predictive of suicidal ideation and behavior within the 6 month post‐assessment period (Yaseen et al., 2014;
Yaseen, Galynker, Briggs, Freed, & Gabbay, 2016). Moreover, higher frantic hopelessness scores were specifically
SCHUCK ET AL. 3

associated with acute suicide attempts (Yaseen et al., 2014). These studies demonstrated strong construct validity for
the suicide trigger state.
In 2017, we renamed the suicide trigger state the Suicide Crisis Syndrome (SCS), primarily to underscore its acuity.
The term “suicide crisis” was coined by Hendin, Maltsberger, and Szanto (2007). In part to pay homage to these distin-
guished suicide researchers, the SCS name was derived from this term, as it was used to describe the intense affective
state preceding an imminent suicide attempt. Further, because the development of the SCS stability and structure was
confirmed by several factor analyses (Galynker et al., 2017; Yaseen et al., 2010; Yaseen et al., 2012; Yaseen et al., 2014),
we felt justified in using the term syndrome in its widely accepted definition of several symptoms that occur together
(American Psychiatric Association, 2013). A prodromal suicidal state was also considered, but its use can be problematic,
as prodromes can last years (as in Bipolar Disorder), while the SCS is a true state phenomenon akin to state anxiety
(Galynker, 2017).
In an attempt to establish the exact phenomenology and the boundaries of the SCS, Yaseen et al. (2016)
examined anhedonia, ruminative flooding/entrapment, state anxiety, and trait anxiety and found each to be signif-
icantly associated with suicidal ideation. When entered together in a model, only anhedonia and entrapment had
independent predictive validity for suicidal ideation over the six months following the assessment. Finally, social
withdrawal was found to be an independent predictor of suicidal thoughts and behaviors in the four weeks follow-
ing the index assessment (Galynker et al., 2017; Yaseen, Hawes, Barzilay, & Galynker, 2018).
Based on this body of SCS research with the STS (later termed Suicide Crisis Inventory, SCI), coupled with pre-
vious research by others on predictors of acute suicidality, we have proposed the DSM criteria for the Suicide Crisis
Syndrome (Galynker, 2017; Yaseen et al., 2018). The purpose of this report is to therefore review empirical evidence
supporting each component of the proposed SCS criteria and to suggest future research directions to gather support
for the inclusion of this suicide‐specific diagnosis into the DSM.

2 | S U I C I D E C R I S I S SY N D R O M E

The Suicide Crisis Syndrome is a pre‐suicidal mental state based on cognitive and affective dysregulation. Though
the diagnosis may identify those at risk for suicide, this is not aimed to be a “diagnosis of risk.” Rather, the SCS
describes the acute mental state that is associated with near‐term suicidal behavior. The SCS is postulated to be
the last phase of the Narrative‐Crisis Model (NCM) where it develops as an emotional crescendo of several differ-
ent but interrelated symptoms as a result of the suicidal narrative (Galynker, 2017). The NCM has been developed
based on previous reports of the life narrative, whereby individuals integrate their experiences into a story of self
(McLean, Pasupathi, & Pals, 2007). The suicidal narrative is therefore conceptualized as a story of self which is
disrupted, making the individual very distressed and unable to imagine a future. It is at this point that the suicidal
narrative leads to a suicidal crisis, or the SCS (Cohen, Ardalan, Yaseen, & Galynker, 2017; Galynker, 2017). The
SCS has five components, separated into two criteria. Both criteria must be met to receive a diagnosis of SCS.
Criterion A is entrapment/frantic hopelessness, or the urgent feeling of needing to escape a perceived inescapable
life situation. Entrapment has been found to be the strongest predictor of near‐term suicidal behavior as well as a
mediator of the relationship between some of the other SCS components and near‐term suicidal behavior (Li et al.,
2017; Li et al., 2018). Criterion B has four categories, each enhancing the predictive validity of Criterion A: affec-
tive disturbance, loss of cognitive control, hyperarousal, and social withdrawal. Each of the four must be present
for Criterion B to be met. Those meeting both Criterion A and Criterion B, as compared with those meeting partial
criteria, are at higher risk for a near‐term suicide attempt (Yaseen et al., 2018).
Past research has outlined the use of each of these SCS components separately in predicting suicide. Our
research involving each symptom and its relation to suicide is included in each section, where applicable. The pro-
posed SCS combines each of these components to create a cohesive syndrome aimed at better predicting imminent
suicide. Symptoms of each criterion are detailed in Box 1, and cited articles reporting associations between SCS
criteria and suicide are outlined in Table 1.
4 SCHUCK ET AL.

TABLE 1 Articles cited in this review that report associations between SCS criteria and suicidal outcomes (SI, sui-
cidal ideation; SB, suicidal behavior; SA, suicide attempts; S, suicide)

Suicidal
Criterion Article Type of study outcome(s)

Entrapment Li et al., 2017 longitudinal SB

Li et al., 2018 cross‐sectional SI
Siddaway, Taylor, Wood, & Schulz, 2015 meta‐analysis SI, SB
Yaseen et al., 2012 cross‐sectional SA
Depressive Yaseen et al., 2018 longitudinal SA
turmoil Fawcett et al., 1987 longitudinal S
Frantic anxiety Kanwar et al., 2013 systematic review SI, SA, S, SB
and meta‐analysis
Goldberg & Fawcett, 2012 meta‐analysis SI and S
Fawcett, Scheftner, Fogg, Clark, & Young, 1990 longitudinal S
Busch, Fawcett, & Jacobs, 2003 longitudinal SA
Katz, Yaseen, Mojtabai, Cohen, & Galynker, 2011 cross‐sectional lifetime SI and
SA
Yaseen, Chartrand, Mojtabai, Bolton, & Galynker, longitudinal SA
2013
Rappaport, Moskowitz, Galynker, & Yaseen, 2014 cross‐sectional lifetime SI and
SA
Anhedonia Ballard et al., 2016 longitudinal SA, S
Spijker, de Graaf, Ten Have, Nolen, & Speckens, 2010 longitudinal SI,SA
Winer et al., 2014 longitudinal SI
Ducasse et al., 2018 meta‐analysis SI
Hawes, Galynker, Barzilay, & Yaseen, 2018 longitudinal SI and previous
SA
Emotional pain Troister, Davis, Lowndes, & Holden, 2013 longitudinal SI and
preparation
Ducasse et al., 2018b meta‐analysis SI, SA
Galynker et al., 2017 longitudinal SB
Ruminations O'Connor & Noyce, 2008 longitudinal SI
Morrison & O'Connor, 2008 systematic review SI, SB
Rogers & Joiner, 2018 cross‐sectional lifetime SA
Rogers & Joiner, 2017 meta‐analysis SI, SA
Miranda & Nolen‐Hoeksema, 2007 longitudinal SI
O'Connor, O'Connor, & Marshall, 2007 longitudinal SI
Cognitive rigidity Marzuk, Hartwell, Leon, & Portera, 2005 concurrent SI
Miranda, Gallagher, Bauchner, Vaysman, & longitudinal SI
Morroquín, 2012
Thought Najmi, Wegner, & Nock, 2007 concurrent SI, SA
suppression Cukrowicz, Ekbald, Cheavens, Rosenthal, & Lynch, cross‐sectional SI
2008
Pettit et al., 2009 cross‐sectional and SI
longitudinal
Ruminative Yaseen et al., 2010 cross‐sectional previous SA
flooding Yaseen et al., 2014 longitudinal SA
Agitation Busch et al., 2003 retrospective S
Rogers, Ringer, & Joiner, 2016 meta‐analysis SA, S
Hypervigilance Ahmadpanah et al., 2017 cross‐sectional previous SA
Yaseen et al., 2018 longitudinal SA
Irritability Conner, Meldrum, Wieczorek, Duberstein, & Welte, cross‐sectional SI
2004
Balázs, Benazzi, Rihmer, Akiskal, & Akiskal, 2006 cross‐sectional SA
Orri et al., 2018 systematic review SI, SA
Insomnia Bjørngaard, Bjerkeset, Romunstad, & Gunnell, 2011 longitudinal S
Fujino, Mizoue, Tokui, & Yoshimura, 2005 longitudinal S
Agargün, Kara, & Solmaz, 1997a cross‐sectional SI

(Continues)
SCHUCK ET AL. 5

TABLE 1 (Continued)

Suicidal
Criterion Article Type of study outcome(s)
Agargün, Kara, & Solmaz, 1997b cross‐sectional SI
Agargün & Kara, 1998 cross‐sectional SI
Drapeau & Nardoff, 2017 narrative review S
Malik et al., 2014 meta‐analysis SI, SA
Pigeon, Pinquart, & Conner, 2012 meta‐analysis SI, SA, and S
Suh et al., 2013 longitudinal SI
Li, Lam, Yu, Zhang, & Wing, 2010 longitudinal SA
Social withdrawal Cukrowicz, Jahn, Graham, Poindexter, & Williams, cross‐sectional SI
2013
Czyz, Berona, & King, 2015 longitudinal SA
Duberstein et al., 2004 retrospective S
Calati et al., in press narrative review SI, SA
Fawcett et al., 1987 longitudinal S
Yaseen et al., 2018 longitudinal SA

2.1 | Diagnostic criteria

2.1.1 | Criterion A: Entrapment

Criterion A describes an SCS sub‐syndrome characterized by persistent and desperate feelings of entrapment. The
early prospective studies of near‐term suicidal behavior using the Suicide Trigger Scales used the term “frantic hope-
lessness” to describe this affective state (Yaseen et al., 2010, 2012, 2014). Each version of the STS used similar items
to represent this construct, but over time the name changed to the more familiar term of entrapment to stay in line
with prevailing terminology. Therefore, both frantic hopelessness and entrapment from previous literature are used
to represent this criterion of the SCS.
Regardless of the term used, this is the core feature of the SCS, and is focused on the urgent feeling of needing
to escape from an intolerable life situation when escape is perceived as impossible (Galynker, 2017), so death may
appear as the only option. Due to previous studies recognizing its centrality to suicide (Li et al., 2017, 2018), entrap-
ment has been given its own criterion. This form of entrapment is the affective state, rather than the cognitive per-
ception of no future.
The inclusion of entrapment in the SCS is consistent with several previous models of suicide, including the cry
of pain model (Williams & Pollock, 2000) and the motivational–volitional theory (O'Connor & Kirtley, 2018). Entrap-
ment is also central to other theories of suicidal behavior (Baumeister, 1990; Johnson, Tarrier, & Gooding, 2008).
According to Gilbert and Allan (1998), entrapment can be conceptualized into two categories, external and internal
entrapment, as the feeling of entrapment can come from both outside events and how these events are perceived
by the individual (Gilbert & Gilbert, 2003; Lazarus & Folkman, 1984). In a meta‐analysis, entrapment was more
strongly associated with suicidal behavior than the feeling of defeat (Siddaway et al., 2015), suggesting a notable
role in suicide. The frantic hopelessness/entrapment subscale of the STS‐3 has emerged as a significant factor,
contributing to the predictive validity of the STS‐3, and was a significant predictor of current suicide attempt
(Yaseen et al., 2012).
Although at present entrapment remains the preferred term for Criterion A because of its acceptability and famil-
iarity, there is some evidence that it is not entirely accurate. First, recent studies have identified emotional pain to be
most highly correlated with entrapment (Galynker et al., 2017; Li et al., 2018). Second, a network analysis of the SCS
(Bloch‐Elkouby et al., unpublished data) has established that entrapment is closely linked to emotional pain. Since
frantic hopelessness can be conceptualized as capturing both entrapment and emotional pain, it may be a more accu-
rate term to reflect this criterion, and the matter is still open to debate.
6 SCHUCK ET AL.

Box 1 Proposed diagnostic criteria for the Suicide Crisis Syndrome

Criterion A: Entrapment/Frantic Hopelessness

Criterion B: Associated Disturbances

1. Affective Disturbance
Manifested in at least one of the following:
• Depressive Turmoil
• Frantic Anxiety
• Acute Anhedonia

• Emotional Pain.
2. Loss of Cognitive Control
Manifested in at least one of the following:
• Ruminations

• Cognitive rigidity
• Thought Suppression
• Ruminative Flooding.
3. Hyperarousal
Manifested in at least one of the following:
• Agitation
• Hypervigilance
• Irritability

• Insomnia.
4. Social Withdrawal
Manifested in at least one of the following:
• social isolation

• evasive communication.

In summary, entrapment has been theorized to be strongly related to suicide, and may play a central role in
predicting imminent suicidal behavior. Entrapment/frantic hopelessness was strongly related to near‐term sui-
cidal thoughts and behaviors (Li et al., 2018; Yaseen et al., 2014). Its role in many models of suicide, coupled
with its significant prediction of imminent suicide, makes entrapment a key criterion in an acute suicide‐specific
diagnosis.

2.1.2 | Criterion B: Associated disturbances

Affective disturbance
Affective disturbance can manifest in several overlapping but distinct symptoms: depressive turmoil, frantic anxiety,
acute anhedonia, and emotional pain. These four manifestations are not mutually exclusive, and, for example, patients
with acute anhedonia may or may not also experience depressive turmoil or frantic anxiety.
SCHUCK ET AL. 7

Depressive turmoil Depressive turmoil is a form of emotion dysregulation, characterized by intense and deep
negative feelings developed over a short period of time (Galynker, 2017). In our study assessing the proposed SCS
criteria, depressive turmoil contributed to the predictive validity in relation to suicidal ideation and attempts (Yaseen
et al., 2018). Depressive turmoil has been previously found to differentiate between those who died by suicide and
those who did not within a four‐year prospective study (Fawcett et al., 1987). In the same study, 31% of those who
died by suicide had experienced depressive turmoil before their death.

Frantic anxiety The next manifestation of affective disturbance is frantic anxiety and panic‐like states. Frantic
anxiety, first described by Fawcett et al. (1990) as psychic anxiety, can be characterized by extreme worry and irrita-
bility, as well as the expectation of the worst possible outcome. This state of anxiety is often associated with somatic
symptoms, such as extreme headaches.
As compared with those without anxiety, individuals with frantic anxiety are more likely to have suicidal thoughts,
behaviors, and attempts, as well as more likely to die by suicide (Kanwar et al., 2013). Overall, a meta‐analysis showed
that the presence of anxiety in other disorders makes suicidal thoughts and attempts more likely (Goldberg & Fawcett,
2012). Fawcett et al. (1990) described extreme anxiety as a critical factor preceding suicidal states. In fact, in the land-
mark prospective study, severe anxiety was significantly related to those who died by suicide within one year of initial
assessment, with 62% of individuals experiencing panic attacks. In relation to imminent suicide, Busch et al. (2003)
found that 79% of individuals had severe anxiety within one week prior to a suicide attempt.
Following Fawcett's pioneering work, Galynker and Yaseen examined the relationships between panic attacks
and specific panic attack symptoms with near‐term suicidal behavior. Specifically, Katz et al. (2011), using the
National Epidemiologic Survey on Alcohol and Related Consequences (NESARC) data analysis, found that past‐year
panic attacks were significantly related to lifetime suicidal ideation and attempts. Within panic attacks, fear of dying
and fear of losing control were more predictive of suicidal behaviors than they were of suicidal ideation. Yaseen et al.
(2013) then found that panic attacks were not predictive of future suicide attempts, but panic attacks featuring fear
of dying were predictive. These individuals were also at a seven times higher risk for a future suicide attempt.
Rappaport et al. (2014) then examined cognitive symptoms in panic attacks, and found them to be significantly pre-
dictive of suicidal ideation.

Acute anhedonia Another characteristic of affective disturbance is acute anhedonia. Anhedonia is a term that
refers to a diminished level of pleasure in activities (Hawes et al., 2018). Anhedonia has been found to be predictive
of future suicidal thoughts, attempts, and behavior (Ballard et al., 2016; Spijker et al., 2010; Winer et al., 2014). A
recent meta‐analysis found that anhedonia was significantly related to current suicidal ideation, even while control-
ling for depression and other psychiatric diagnoses (Ducasse et al., 2018b). Though many previous accounts report
the effect of high levels of chronic anhedonia, our recent research suggests that it is acute anhedonia, rather than
chronic, that is prospectively predictive of suicide (Hawes et al., 2018).

Emotional pain Several researchers and theorists suggested that emotional pain is a key component of suicidal
behavior (Barzilay & Apter, 2014). Also termed psychological pain, psychache, or mental pain, emotional pain can
be defined as intense unpleasant negative emotions which may be characterized by feelings of hurt, anguish, bro-
kenness, and being wounded (Bolger, 1999; Meerwijk & Weiss, 2011; Shneidman, 1999). The concept of psycho-
logical pain and its relation to suicidality dates back to Shneidman (1987), as he postulated that it may become so
intolerable that it results in suicide. He also argued that, even if other symptoms are present, it is because of their
relation to psychological pain, and suicide would not occur without it (Shneidman, 1993). In fact, emotional pain
has been significantly associated with suicidal ideation and preparation even when controlling for depression
and hopelessness, which are typically associated with suicide (Troister et al., 2013). Therefore, although emotional
pain is highly related to depression and anxiety, it is believed to be a separate entity (Galynker, 2017). A recent
8 SCHUCK ET AL.

meta‐analysis also revealed that the experience of emotional pain was predictive of current suicidal ideation and
attempts (Ducasse et al., 2018), suggesting its role in imminent suicide. Our studies with the STS found that emo-
tional pain was a significant predictor of suicidal behavior within a month (Galynker et al., 2017). It must be noted
that emotional pain may be strongly linked to entrapment (Bloch‐Elkouby et al., unpublished data), as suggested by
the concept of “frantic hopelessness,” and future research may uncover emotional pain to be part of Criterion A.

Loss of cognitive control

Loss of cognitive control includes ruminations, cognitive rigidity, thought suppression, and ruminative flooding. The
first three symptoms have been widely studied in relation to suicide, while ruminative flooding was described more
recently by Yaseen and Galynker in several prospective studies (Yaseen et al., 2010, 2012, 2014).

Ruminations Ruminations can be broadly defined as the tendency to repetitively think of one's own distress
(Nolen‐Hoeksema, 1991). They have been described as either brooding or reflective pondering (Treynor, Gonzalez,
& Nolen‐Hoeksema, 2003). Brooding rumination has been found to predict suicidal ideation within three months,
whereas reflective pondering does not (O'Connor & Noyce, 2008). Often, increased rumination causes individuals
to focus on perceived unescapable life situations. This can increase feelings of entrapment and therefore facilitate
entry into the suicidal crisis (Galynker, 2017). Ruminations can be suicide specific (Rogers & Joiner, 2016),
manifesting in repetitive thoughts associated with suicidal thoughts and suicide attempts (Morrison & O'Connor,
2008). Recently, Rogers and Joiner (2018) found that suicide‐specific rumination was significantly associated with
lifetime suicide attempt beyond general rumination and other known risk factors. Rumination has repeatedly been
found to be significantly associated with suicidal thoughts and behaviors (Morrison & O'Connor, 2008; Rogers &
Joiner, 2017). It has also been prospectively related to suicidal ideation within one year (Miranda & Nolen‐
Hoeksema, 2007), three months (O'Connor & Noyce, 2008), and eight weeks (O'Connor et al., 2007).

Cognitive rigidity Another component of loss of cognitive control is cognitive rigidity, which has long been stud-
ied in relation to suicide (Breed, 1972; Neuringer, 1964). One part of the suicidal crisis is a rigid thought process
(Halari et al., 2009), as it makes individuals refute any other possible solutions besides suicide (Obegi, 2018). Cogni-
tive rigidity is often found in those who have made a suicide attempt or have history of suicidal thoughts or behaviors
(Marzuk et al., 2005), and has been prospectively predictive of suicide among those with a previous suicide attempt
(Miranda et al., 2012).

Thought suppression Thought suppression is the purposeful act of attempting to not think of something, typically
something unpleasant (Cukrowicz et al., 2008). This factor is often associated with those who have difficulty regulat-
ing their emotions (Wegner & Zanakos, 1994), which can be common in suicidal patients (Najmi et al., 2007; Pettit
et al., 2009). When an individual attempts to suppress his or her thoughts, the result can often be the opposite,
thereby intensifying the thoughts (Wegner, Schneider, Carter, & White, 1987), which can be applied to suicidal think-
ing. The tendency to suppress thoughts has been found to be significantly associated with suicidal ideation among
older adults, when controlling for depressive symptoms (Cukrowicz et al., 2008). It has also been associated with con-
current and prospective suicidal ideation (Pettit et al., 2009).

Ruminative flooding Ruminative flooding is defined by a more intense form of rumination, distinct in its associ-
ated somatic symptoms of head pain or head pressure (Yaseen et al., 2012, 2014, 2016). Patients describe this as
being distinct from a typical headache. This is a construct that has been developed by our group, based on our pre-
vious research and clinical expertise. In several prospective studies with different patient populations, ruminative
flooding has emerged as a factor on each version of the STS, and is strongly related to suicidal behavior (Yaseen
et al., 2010, 2014).
SCHUCK ET AL. 9

Hyperarousal
This part of Criterion B has been included in more recent research. Hyperarousal has been identified as an acute risk
factor for suicide (Chu et al., 2015). It can manifest in agitation, hypervigilance, irritability, and insomnia.

Agitation Agitation occurs when psychological and physical arousal are heightened, and the individual may feel
restless (Ribeiro, Bender, Selby, Hames, & Joiner, 2011) or nervous or tense (Robins, 1981). Notably, it has been
found that 50% of individuals reported extreme agitation within one week prior to their death by suicide (Busch
et al., 2003). In a recent meta‐analysis, there was an association between agitation and those who attempted and
died by suicide (Rogers et al., 2016), with agitation being more strongly related to individuals who died by suicide
than those who attempted suicide, suggesting a possible correlate of lethality.

Hypervigilance Hypervigilance can be described as an increase in sensory awareness and sensitivity to potential
dangers (Rollman, 2009). It has been found to increase levels of anxiety (Taylor, Gooding, Wood, & Tarrier, 2011),
which can in turn increase risk for suicide. In individuals with depression, those with a suicide attempt history had
higher hypervigilance scores than those who did not have a suicide history (Ahmadpanah et al., 2017). In our study
using the proposed SCS criteria, hypervigilance contributed to the predictive validity of the diagnosis (Yaseen
et al., 2018).

Irritability Irritability is the next manifestation of hyperarousal, and has been found to be significantly related to
suicidal ideation (Conner et al., 2004). Balázs et al. (2006) found irritability to be significantly associated with near‐
term suicide, with irritability and psychomotor agitation emerging as the strongest predictors of suicide attempts.
In a recent systematic review, irritability was strongly related to suicide in various clinical samples (Orri et al.,
2018). Specifically, results on the association between irritability and suicidal ideation are mixed, but irritability was
significantly associated with attempted suicide in each included study.

Insomnia Insomnia can be characterized by difficulty falling asleep and/or staying asleep. In general, sleep prob-
lems have been associated with an increased prospective risk for suicide (Bjørngaard et al., 2011; Fujino et al.,
2005). In those with major depression or panic disorder, insomnia and sleep disturbances have been found to be
related to suicidal behavior (Agargün et al., 1997a, 1997b; Agargün & Kara, 1998). Insomnia has been found in up
to 37% of suicide decedents (Drapeau & Nardoff, 2017). One meta‐analysis found that insomnia significantly
increased the risk of suicidal ideation and suicide attempts (Malik et al., 2014), and another meta‐analysis further
found that this relationship was still significant when controlling for depression (Pigeon et al., 2012). Interestingly,
among those who did not have a depressive disorder, persistent insomnia increased the risk of suicidal ideation pro-
spectively (Suh et al., 2013). Insomnia has also been found to be significantly associated with suicide attempts one
year after initial assessment (Li et al., 2010).

Social withdrawal
The final component of Criterion B is social withdrawal, and is largely based on the interpersonal theory of suicide
(Van Orden et al., 2010). It is derived from the human need for connection being unmet (Baumeister & Leary,
1995). Social isolation has been found to be one of the strongest predictors of suicidal thoughts and behaviors among
various populations (Cukrowicz et al., 2013; Czyz et al., 2015). Those who have been isolated, whether physically or
psychologically, are more likely to die by suicide (Duberstein et al., 2004) even when controlling for mood disorders
and unemployment. A recent narrative review found that social isolation was significantly related to suicidal ideation
and suicide attempts (Calati et al., 2018). A prospective study found that social withdrawal discriminated between
those who died by suicide and those who did not (Fawcett et al., 1987).
10 SCHUCK ET AL.

Finally, Yaseen et al. (2018) used the Visual Analog Scale to assess individuals' feelings of connectedness to their
support network. When Criterion A of the SCS was coupled with social withdrawal, it had the highest specificity
(91.5%), positive predictive value (33.3%), and negative predictive value (95.6%) for post‐discharge suicide attempt,
in comparison with other symptoms separately coupled with Criterion A. Social withdrawal also contributed to the
predictive validity of the proposed DSM criteria in relation to prospective suicide attempt. More research is needed
to understand the relationship between social withdrawal and suicidal ideation and attempts, to further differentiate
this construct from social isolation.

3 | DISCUSSION

Suicide research has a long history, and our understanding of suicide has evolved over time. Despite valiant efforts by
research and clinical groups around the world, suicide remains difficult to predict, and suicide rates have continued to
increase in the last 20 years (Centers for Disease Control and Prevention, 2016). Recent research suggesting the use
of a suicidal diagnosis has been promising (Tucker, Michaels, Rogers, Wingate, & Joiner, 2016; Yaseen et al., 2018),
and the development of such a diagnosis may be critical to patient care.
The Suicide Crisis Syndrome (SCS) includes five main components, each of which must be met to receive a diag-
nosis. Each component has been included based on research that revealed strong independent relations to suicidal
behavior, but this is the first model to investigate the components together as a unified syndrome. The five factors
of the SCS—entrapment, affective disturbance, loss of cognitive control, hyperarousal, and social withdrawal—
together create a cohesive syndrome, aimed at capturing all the mental, behavioral, and emotional states preceding
a near‐term suicide attempt.
Recent research by our group has started to investigate the associations between the five components of the
SCS and prospective suicidal ideation. Previous studies using the Suicide Crisis Inventory (SCI; previously termed
the Suicide Trigger Scale (STS)), a self‐report measure of most of the SCS components, have found strong
associations with suicidal behavior. A recent study by our group is the first to assess the proposed DSM criteria
and its relation to suicidal behaviors among an inpatient population (Yaseen et al., 2018). Results of the study
revealed that those who met criteria for the SCS, as compared with those who did not meet criteria, had signif-
icantly more severe suicidal ideation in the previous week. Prospectively, individuals who met SCS criteria were
nearly seven times more likely to have a suicide attempt within 4–8 weeks following inpatient discharge. Further,
the SCS was predictive of post‐discharge suicide attempts when controlling for current SI and depressive severity.
In contrast, both current suicidal ideation and depressive severity were not predictive when controlling for the
SCS. Finally, the full criteria for the SCS (combining Criteria A and B) were maximally predictive (sensitivity = 44.4%,
specificity = 92.8%, positive predictive value = 36.4%, negative predictive value = 94.7%) in comparison with only
partial criteria, suggesting that each component is necessary in prediction of imminent suicide. Further, our recent
network analysis has demonstrated that many of these symptoms are highly correlated (Bjørngaard et al., 2011).
These initial results show support for the utility of the SCS. More research is needed to better understand how
each criterion interacts with the others and how we can best utilize the diagnosis to identify those individuals who
are experiencing this acute mental state associated with near‐term suicidal behavior.

3.1 | Implications

The implications of the ability to diagnose suicide are profound, highlighted by clarification, communication, treat-
ment, and predicting future management needs and outcomes (Obegi, 2018). These are important to consider in
understanding the crucial nature of diagnosing a pre‐suicidal mental state. If clinicians were provided with a
SCHUCK ET AL. 11

diagnosable syndrome, they could more systematically identify those who may be at risk, and would be able to pro-
vide the necessary treatment to help reduce the risk of a suicide attempt.
A patient's suicide attempt has been found to be extremely stressful for the clinician (Berman, Stark, Cooperman,
Wilhelm, & Cohen, 2015). The emotional burden that comes with this event is critical to understand. Beyond personal
experience with a patient's suicide attempt, there are often legal ramifications. Lawyers can argue that the clinician
did not employ the necessary interventions, and this attempt could have been avoided if the clinician had acted
sooner. Therefore, it is crucial that clinicians are provided with the proper tools to identify and treat individuals
who are at imminent risk for suicide. The SCS diagnosis would be a clear tool for these clinicians.
Although an argument can be made for legal responsibility of clinicians should they employ such a diagnosis, the
opposite may in fact be true (Joiner, Simpson, Rogers, Stanley, & Galynker, 2018). When a patient dies by suicide, a
lawsuit arguing for medical malpractice would include determining if proper steps have been taken for the mitigation
of his/her suicide risk. A standardized instrument such as a suicide‐specific diagnosis could introduce a systematic
way of identifying those individuals who may be at imminent risk for suicide. This could influence treatment planning
and help clinicians refer patients to the most appropriate resources, such as admission to a psychiatric inpatient facil-
ity. The use of the diagnosis would provide ease of communication between treatment teams, as the patient's symp-
toms and suicide risk would be clear. Proper assessment, treatment, and safety planning could then be employed to
help this patient. Through these actions, the clinician can reduce the legal burden, as proper steps have been taken to
manage the risk of a near‐term attempt.

3.2 | Future directions

This review was aimed at developing a framework for the use of each component of the SCS. Future research should
focus on not only each component, but also the entire syndrome and its relation to imminent suicide. Specifically,
better understanding is needed in reference to the development of the diagnosis for the DSM. First, we need to
establish a time course for the illness. Though the SCS is proposed to develop within a short period of time, we must
employ research to understand if a diagnosis of SCS must be within a time frame (i.e., symptoms appearing within one
week). Next, we must determine if external events are required for diagnosis. In the NCM, a stressful life event is pro-
posed to precede the suicide crisis. It must be well established if this event must occur in order to receive the diag-
nosis. Next, we must see if the SCS occurs independently from or co‐morbidly with other disorders. For example, if a
patient has a diagnosis of Borderline Personality Disorder, does this disqualify the patient from receiving a diagnosis
of SCS? Indeed, some of the symptoms may overlap, and this is an important point to consider. Finally, we must
establish whether the SCS could be meaningfully subdivided into mild, moderate, and severe sub‐syndromes, corre-
sponding to mild, moderate, or severe risk for imminent suicide. Further research is needed to answer each of these
questions.
Future research should focus on short follow‐ups (i.e., within a few days or weeks), to better understand each of
these components in relation to imminent suicidal behavior. Due to the large percentage of individuals who do not
have a psychiatric diagnosis at the time of their death by suicide, it is necessary to establish these relationships in
both clinical and community samples. It also must be noted that a wide variety of the research done has focused
on adult samples, and our studies have included individuals between the ages of 18 and 65. More research is needed
to understand how these symptoms can be related to both adolescent and older adult populations.
Finally, it is possible that a singular approach to suicide risk assessment is not sufficient. There is evidence that
modular assessments, such as the Modular Assessment of Risk for Imminent Suicide (MARIS; Hawes, Yaseen, Briggs,
& Galynker, 2017), which includes both patient and clinician components, may be better suited for capturing all indi-
viduals who are at risk. Future research should also focus on these modular assessments to understand their relation
to a pre‐suicidal mental state. Through these various methods, the SCS will have the potential to become a solidified
12 SCHUCK ET AL.

diagnosis with the capability of better identifying individuals at risk for an imminent suicide attempt and ultimately,
reducing suicide rates.

4 | C O N CL U S I O N

The Suicide Crisis Syndrome (SCS) was developed to identify the acute cognitive–affective state associated with immi-
nent suicidal behavior. The SCS has five main evidence‐based components, separated into Criterion A, entrapment, and
Criterion B, affective disturbance, loss of cognitive control, hyperarousal, and social withdrawal. The implications of a
suicide‐specific diagnosis are far reaching. Beyond its capacity to provide crucial information about the mental state
associated with imminent suicide, the SCS may bring about a drastic improvement in clinicians' ability to identify indi-
viduals at risk. Throughout this article we have reviewed the empirical evidence that supports the inclusion of each
of its criteria and symptoms in one cohesive proposed diagnosis. Further research is needed to determine the exact
boundaries, timeframe of onset, and potential overlap of the SCS with other conditions. The initial results involving
the SCS have been promising. Further development of the SCS diagnosis is therefore warranted, as identification of
individuals who manifest it is critical.

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How to cite this article: Schuck A, Calati R, Barzilay S, Bloch‐Elkouby S, Galynker I. Suicide Crisis Syndrome:
A review of supporting evidence for a new suicide‐specific diagnosis. Behav Sci Law. 2019;1–17. https://doi.
org/10.1002/bsl.2397