Category: Bipolar Disorder

Review ASAD: Acute Suicidal Affective Disturbance

This article was written earlier this year and I was able to get it to evaluate it. The following are my thoughts about it:

Suicide affects over 800,000 people worldwide but there is not much in terms of preventing death by suicide or attempts. Risk factors mostly focus on suicide ideation. Even though the DSM 5 has created a SBD (suicidal behavior disorder), it is something to be explored but not a full diagnosis. The authors of this article have proposed the diagnosis of Acute Suicidal Affective Disturbance because it is a relatively immediate response to stress or some other factor. The criteria is:

• A geometric increase in suicidal intent over the course of hours or days, as opposed to weeks or months
• One of both of the following: marked social alienation (e.g., severe social withdrawal, disgust with others, perceptions that one is a burden on others) or marked self-alienation (e.g., self-disgust, perceptions that one’s psychological pain is a burden)
• Perceptions that the foregoing are hopelessly intractable
• Two or more manifestations of overarousal (i.e., agitation, insomnia, nightmares, irritability)

All four criteria must be present for a diagnosis and must not be the direct result of an exasperation of a mood disorder or substance use. I am guessing this means that a mixed state would exclude the diagnosis. I also wrote to the primary author, Megan Rogers, to find out if a medical condition would be exclusionary, such as a chronic pain condition, but it hasn’t been established.

Exclusionary criteria for the studies were active psychotic symptoms, imminent danger to self or others, and unmedicated bipolar spectrum disorders.

343 outpatients from a university-affiliated clinic were enrolled in the study. Various measures were used to assess anxiety, depression, suicide ideation, anger, dream activity, etc. 7,698 inpatients were enrolled in the second part of the study. Measures were a little different than the outpatient sample, as the SSF-II (Suicide Status Form) was used to measure ASAD symptoms as opposed to the Beck Scale for Suicide Ideation. The SSF-II has a good validity rate (Jobes et.al., 1997). Other measures were length of stay (mean 7.54 days, SD 6.41), PHQ-9, and past suicide attempts.
The statistics of the tables were confusing to me as I am not a stats person so I can’t really interpret the results. The discussion had good markers for ASAD being a diagnosis and I went from there. One take away was that ASAD was associated with numerous psych disorders but was not redundant in association to suicide risk. It was related to past suicide attempts above and beyond symptoms of depression, which I think is important. Depression symptoms only tell one side of the story and not all people with depression are suicidal or have thoughts of suicide.

As with this being relatively new, more research is needed in multiple areas to ascertain whether this can be a useful diagnosis in the management of suicidal behaviors or even to prevent suicide. The authors did note that once ASAD is established, good safety planning is necessary to monitor suicidality throughout the course of treatment. This is important in all therapeutic endeavors when dealing with suicidal individuals, even if the episode has passed. A tailor made plan must be made, not a “one size fits all” model.

Acute Suicidal affective disturbance: Factorial structure and initial validation across psychiatric outpatient and inpatient samples. Rogers,M. Chiurliza, B. Hagan, CR. Tzoneva, M., Hames, JL., Michaels, MS., Hitchfield, MJ., Palmer, BA., Lineberry, TW.,Jobes, DA., Joiner, TE. Journal of Affective Disorders 211 (2017) 1-11