In medicine, there are some serious conditions that announce their presence with acute authority. Take for example, migratory thrombophlebitis, epidural hematoma, and acute asthma with measurable predictive x-ray or blood biomarkers narrowing diagnostic decisions.
What about current and significant biomarkers in suicidal behavior to discriminate extreme, often unobvious acuity from unremitting chronicity? Is there a sine qua non, even one predictor, even one diagnostic test of foreseeability with efficacy for its critical emergence in even one cohort?
Suicide represents a complex and complicated family of variable conditions. Some self-destructive patterns are recurrent, containable, controllable, and less lethal as demonstrated in many personality disorders. Others may represent acutely disorganized thought or mood disorders with compelling and convincing auditory commands demanding death. There are also acute, atypical, partially present, and such that they do not yet meet contemporary diagnostic criteria or collegial consensus.
Let's explore the example of youth adjustment disorder (AD) -- which is often associated -- to discuss potential biomarkers for predicting suicide.
The Youth AD Family Member
One such specific, special, and dangerous family of conditions is youth acute adjustment disorder (AD). The in these victims appears to be short and rapidly evolving. In these instances, precipitated by a single proximal stressor, it is the salience of the interpersonal crisis to the person, not the perceived severity interpreted by outsiders (even evaluators), which controls the life-death balance. I have previously described a form of dynamic agitation (quantifiably measurable), consistent with extrapyramidal dysregulation, which may ultimately provide diagnostic efficacy in these highly lethal, expanding small tail distribution cases.
In practice, AD requires diagnostic dimensionality, a higher threshold beyond a simplistic depression entry. Without such consideration, harmful, potentially fatal complications are likely a result of incomplete diagnosis, intervention, and stabilization. Unfortunately, this legitimate diagnosis has regularly fallen out of favor and is often considered the overmedicalization of personal misfortune. Others subsume the AD diagnosis within a more general description of ubiquitous depression. face reimbursement difficulties in part on the basis of network conflicts, and rightful confusion regarding point-of-care risk-coder tools.
The Ideation-Centric Fallacy
Past as well as has shown that currently well-braced ideation assessments are, without consideration to other dysregulated factors, insensitive to risk in the ED.
Yet, those who stubbornly parrot ideation-centric eccentricity in yes-no, either-or, non-dimensional determinations, are jeopardizing persons in acute need. It is the thinking of simplistic division without curiosity, innovation, or cross disciplinary observation. It falls short of even one dimension of complexity.
On the contrary, it is the clinician's index of suspicion that can mitigate unnecessary harms through competent training, experience, pathophysiologic understanding, and ultimately, effective diagnostic testing. The latter represents systematic discovery, development, and validation of a biomarker with pioneering, yet "older" statistical methods to detect early-stage, life threatening disease.
The Marker
So, what does a validated biomarker in AD look like?
I've previously reported a between youth suicide with or without disclosed, elicited, or cortically hijacked ideation and impaired ability to perform dominant hand rapid alternating "go-no-go" movements (RAM) or dysdiadochokinesia (DDK) in AD. I hypothesized that the unusual coupling of impaired executive performance -- further positively correlated with the Barnes Akathisia Rating Scale (BARS) with AD and the significant vulnerability to suicide mortality -- represented an acute cognitive state diathesis beyond social and environmental factors.
Recent retrospective analyses of my earlier published data confirm that the presence of neuropsychological dysregulation and polymorphic akathisia-like deficits, alone or in combination, in the presence or absence of a pure AD diagnosis, with or without ideation, accelerates a one-step suicide transition to extreme risk in these cases, confirmed utilizing intricate Bayes' likelihood ratio and Markov chain probabilities.
To summarize the statistical findings:
- A strong relationship between late appearing dysexecutive factors (dissociation, agitation, cognitive rigidity) in youth (N=43) without ideation (state "i") and risk for near future lethal attempt (state "j") within minutes was demonstrated.
- An equation for suicidal lethality was retrospectively constructed in survived, resuscitated near-hanging cases and tested for validity utilizing reverse, inverted Markov analysis, similar to a statistical, quantitative psychological autopsy.
- Binary positive likelihood ratios (LR+), an important measure of individual rather than prevalence diagnostic accuracy, calculated from stage sensitivity and specificity values, ranged greater than 10. Multistage LR+ ranges were 37-42.
- Many of these cases also featured rapid, all-or-none propagation of dissociative-like symptoms (i.e., detachment, with rapid transition, reminiscent of stress-elicited anaphylaxis).
- Quantifying and comparing these findings with , where the odds ratio (OR) for AD and completed suicide revealed 12 times the rate of suicide as those without the diagnosis, the corresponding probability in the new retrospective analysis was approximately 0.92.
- The bedside statistically valid DDK RAM test is applicable to ED and other clinical settings, including a phonic, alpha-numeric rapid alternating fluency (RAF) version for 988 crisis hotlines.
Conclusion
These findings speak to the importance of suspecting and understanding rapid, autonomous suicide probabilities as acute and reliable biomarkers in youth, and assessing neurocognitive functioning, regardless of ideation, quickly in the ED.
There is no substitute for observation in science. What is seen and unseen is essential to the scientific method and in the collection of data. It cannot be replaced, for it enables the construction of meaningful hypotheses and theories. As Louis Pasteur observed, "In the fields of observation, chance favors only the prepared mind."
Russell Copelan, MD (Ret.), lives in Pensacola, Florida. He graduated from Stanford University and UCLA Medical School. He trained in neurosurgery and completed residency and fellowship in emergency department psychiatry at UC Irvine and University of Colorado, Denver. He is a reviewer for Academic Psychiatry and founder of eMed Logic, a non-profit originator and distributor of violence assessments. Copelan is also a presenter for the National Association of School Psychologists (NASP) Speaker's Bureau, and a consultant to the American Association of Suicidology.