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Suicide Prevention with Dr. Igor Galynker
131 Plays1 month ago
On today's episode of Doorknob Comments, Fara and Grant are joined by Igor Galynker, a psychiatrist, clinician, and researcher known for his work in bipolar disorder, suicide prevention, and the role of family dynamics in psychiatric illness, who currently serves as the Associate Chairman for Research in the department of psychiatry at Mount Sinai Beth Israel. Dr. Galynker talks about how he got interested in exploring suicide prevention, the signs that typically appear before someone commits suicide, and how therapists can better attune themselves to these markers.
We hope you enjoy.
If you or someone you know is experiencing suicidal thoughts or is in crisis, please seek help immediately by contacting the 988 Suicide & Crisis Lifeline, visiting the nearest emergency department, or calling 911.
Resources and Links
Doorknob Comments
https://www.doorknobcomments.com/
Dr. Igor Galynker
https://profiles.mountsinai.org/igor-galynker
https://labs.icahn.mssm.edu/galynkerlab/
https://www.bpfamily.org/about-2
Dr. Fara White
Dr. Grant Brenner
Recommended
Transcript
Introduction to Emotional Suppression in Professionals
00:00:00
Speaker
You should trust your feelings. Absolutely. And you should not suppress them, ah which kind of puts us clinicians in a bind, because we're trained to suppress the feeling. It's called professionalism and behaving a certain way. But what we need to do is that we need to feel, have a feeling, identify it, and then manage it, which is a very different story from suppressing Hello, I'm Dr. Farrah White.
Origin of Doorknob Comments Podcast
00:00:25
Speaker
And I'm Dr. Grant Brenner. We're psychiatrists and therapists in private practice in New York. We started this podcast in 2019 to draw attention to a phenomenon called the doorknob comment. Doorknob comments are important things we all say from time to time, just as we're leaving the office, sometimes literally hand on the doorknob. Doorknob comments happen not only during therapy, but also in everyday life. The point is that sometimes we aren't sure how to express the deeply meaningful things we're feeling, thinking, and experiencing.
00:00:54
Speaker
Maybe we're afraid to bring certain things out into the open or are on the fence about wanting to discuss them. Sometimes we know we've got something we're unsure about sharing and are keeping it to ourselves. And sometimes we surprise ourselves by what comes out.
00:01:09
Speaker
Welcome to the Doorknob
Guest Introduction: Dr. Igor Glinker
00:01:10
Speaker
Comments Podcast. I'm Grant Brenner. I'm here with my co-host, Dr. Farrah White. And we are very pleased to have today our guest, Dr. Igor Glinker. Dr. Glinker is an American psychiatrist, clinician, and researcher known for his work in bipolar disorder, suicide prevention, and the role of family dynamics in psychiatric illness.
00:01:29
Speaker
He is currently the Associate Chairman for Research in the Department of Psychiatry at Mount Sinai Beth Israel and serves as the founder and director of the Family Center for Bipolar Disorder as well as the Mount Sinai Suicide Research and Prevention Laboratory.
00:01:42
Speaker
He is also a professor of psychiatry at the ICANN School of Medicine at Mount Sinai in New York City. Welcome, Dr. Glinker.
Understanding Suicidal Mental States
00:01:50
Speaker
Thank you for having me. Pleasure to be here.
00:01:53
Speaker
yeah So today we're going to be talking about suicide prediction, prevention and everything to do with that, which is an area of specialization. Yes. And I know that you've been you know you've had a quite an illustrious career, did some teaching of residents. so we actually know each other from when I was in training.
00:02:13
Speaker
i think that the audience would want to hear a little bit how you came to this topic as you know your main research and why you decided to dedicate yourself to Well, ah that's a good place to start.
00:02:30
Speaker
ah so I'll be happy to tell you that, because I actually thought about it quite a bit retrospectively. And there are actually two reasons why I became a suicide prevention researcher.
00:02:44
Speaker
ah after being a bipolar researcher for a while, meaning research and bipolar disorders, ah there's a conscious reason and subconscious reason. So the conscious reason was ah that about 2007,
00:03:01
Speaker
ah Then ah the medical director of the American Foundation for Suicide Prevention, Paula Clayton, gave a talk at Beth Israel about suicide prevention and the organization.
00:03:13
Speaker
And there was a lot of serotonin impulsivity, brain imaging, ah genetics in that talk. And there was nothing said about suicidal mental state.
00:03:25
Speaker
And after the talk, I gave... um ask our question is that, well, this is all well and good. But do you actually know what's in the person's mind day they kill themselves, which is different from the day before?
Impact of Patient Suicide on Clinicians
00:03:41
Speaker
or in the appointment, last appointment, when you see them as a clinician from the appointment before. And ah she said, No, we don't. And at that point, I realized that we have a giant gap in our knowledge in suicide prevention.
00:03:58
Speaker
And the ah that is a description of suicidal mental state, that we were focusing actually on something entirely different. So um that was a conscious reason.
00:04:09
Speaker
The subconscious reason was that about 10 years prior to that, I lost a patient to suicide. And that was in my second year as an attending at Beth Israel.
00:04:22
Speaker
ah And the the patient was referred to me to my ah chairman at the time, Dr. Winston, who was, ah you know, grizzled, a very experienced clinician who didn't want to deal with the case.
00:04:36
Speaker
Okay, and actually sent to me as i understand right now. So he was 53 year old um gay man who ended up with the following story.
00:04:47
Speaker
He had a partner who was, and ah think, North Korean defector that he lived with for 20 years. My partner was working in a restaurant as a busboy.
00:04:59
Speaker
And um they lived together happily for 20 years. And then the partner got actually liver cancer. And the my patient took him home. And then he died there at home in my patient's arms, so to speak.
00:05:14
Speaker
And then when he started making funeral arrangements, his wife, ah the partner's wife and three children, all of them teenagers, okay, showed up at the funeral.
00:05:25
Speaker
So it turns out that the partner led a double life. Okay, he had a second family and and the patient didn't know anything and absolutely shattered his world. Okay. And the fairy tale.
00:05:38
Speaker
And I tried very hard to reframe it, uh, to, uh, um, open some doors for a future um unsuccessfully. And at one point, uh, he said, well, I think I'm going to try to do what you're telling me.
00:05:53
Speaker
And, uh, then, uh, so I'm going to go to Thailand and see if I find another Asian man, you know, but younger model and see what happens. And so he did.
00:06:04
Speaker
And it so it felt a bit strange to me at the time, but he did, left. And then a day later, I got a call from the local precinct that he killed himself.
00:06:15
Speaker
He planned it actually recently, but carefully. And then a week later, I got a letter from him. sent before he died, and a gift, actually a package, and saying, doc doctor, you did everything you could, I mean, don't blame yourself, that's just kind of how it needs it needed to be.
00:06:33
Speaker
And so obviously, it affected me. And it took me a while to process that. But I didn't realize at the time how deeply the story actually a touched me. And um then when the second thing happened, I realized that, you know, this unique opportunity, meaning, ah which by the way, rarely happens in medicine, is that you have a missed syndrome, which is suicidal mental state.
00:07:02
Speaker
ah that nobody knows about, that's a key to suicide prevention, that is probably staring everybody in the face and here's it undescribed.
Suicidal Ideation vs. Behavior
00:07:11
Speaker
And so at that point, I quit bipolar research and started dealing with suicide prevention, describing suicidal mental state.
00:07:18
Speaker
So that was now years ago. It's such a a tragic story and something a lot of us will inevitably go through in our career.
00:07:30
Speaker
Yes. ah Well, it also depends. It depends on what you what you do and what kind of patients you see. Some people may not have a patient who dies by suicide if they deal with low low risk population.
00:07:46
Speaker
And ah some doctors will have several. I mean, I had actually three people who died by suicide over a period of about 35 years now, because I work with the very acute, acute people.
00:08:01
Speaker
And what they all had in common, and but nine people died by suicide after they left me within my treatment for about and about a month, within within a month.
00:08:13
Speaker
And all what all of them had in common is that everyone at the time denied suicidal ideation. Otherwise, i would have probably hospitalized them at a time or intensified the treatment.
00:08:25
Speaker
ah But ah that ah can inform the framework that suicidal ideation will not be part of the syndrome. It may or may not be there, but it's not critical and and it's misleading.
00:08:38
Speaker
And in later research, what we discovered is that the syndrome as we described it, and you know, I can talk about it more if you would like me to, let's say has a certain predictive validity for suicidal behavior, let's say 90% within a month.
00:08:53
Speaker
And
Clinicians' Emotional Paradox
00:08:54
Speaker
if you add suicide radiation to it, it changes by 1% to 91%. tonight you up So that factor doesn't make much of a difference? It has about as much predictive validity as ah severe anxiety with strange strange sensations you never felt before.
00:09:12
Speaker
Which people, by the way, would tell you much more readily about than their suicide radiation quite often. When you mentioned that unconscious thought, you connected it later.
00:09:24
Speaker
You mentioned in the last session that you saw him that there was something strange about it. Do you have a sense of what that was looking back? Because I know that's one of the things in the suicide literature we talk about is that feeling that the therapist or the psychiatrist sometimes has, and it can be hard to kind of register.
00:09:45
Speaker
Yes, we actually looked into this. So the framework for our research was, is that we psychiatrists, and so I at the time had the feeling that we didn't know what it was that we couldn't characterize, that the patient had suicidal ideation in their mind, and we didn't know what it was.
00:10:07
Speaker
And then we didn't communicate. What we did is that we researched both the suicidal state of mind, state of mind, as well as the clinician's emotional response, and then put it together.
00:10:19
Speaker
It's actually, the feeling is now pretty well defined. There's several feelings that you would have you can identify. One is just your own feeling of distress, just plain distress.
00:10:30
Speaker
And it is something ah that, which is ah ah out of the ordinary for the situation. i mean, that you have a discomfort and distress. The second feeling is what we call anxious over-involvement.
00:10:46
Speaker
And it's a paradoxical feeling, meaning ah it's a combination of hope and ah ah anxiety. If you are hopeful for the patient and you think that the patient is going to be fine, that should calm you down.
00:11:01
Speaker
okay And yet at the same time, you feel very stressed and you overextend yourself ah to the patient and start doing things that you typically don't do, such as answering phone calls and more frequently and calling them and checking how they're doing.
00:11:15
Speaker
So this is the second emotion. This is a sign that the risk is high, as well as distress. It's paradoxical feeling, like a part of you is hopeful, but a part of you is not just not buying it.
00:11:27
Speaker
Absolutely. And the other one is another paradoxical feeling, ah which we call collusion abandonment ah or distancing.
00:11:38
Speaker
And it's a combination of hopelessness and calm. The first one was hope and distress. And the second one is hopelessness and calm, meaning you know, okay, you know that the not only that the patient may kill himself.
00:11:56
Speaker
And you may also even think that, well, if I was in his shoes, I would kill myself too. Or maybe, I mean, maybe that is the way to go. That's the collusion. Yes. At the same time, you don't feel a thing.
00:12:09
Speaker
Okay. You just want to actually distance yourself from the situation. So maybe something like a dissociative response. Right. Mm-hmm. So that's the third feeling. and um And when I do rounds, usually ah with ah what i do research assistants and ah previously with the residents, we actually examine our feelings when we talk to suicidal patients. And this is part of the rounds ah that we have. And I'll call it countertransference rounds when people need to first learn to separate their feelings from their thoughts, which is not an easy thing
00:12:47
Speaker
ah by the way, ah for a lot of people, but this is something that we train people in. You should trust your feelings, absolutely. And you should not suppress them, ah which kind of puts us clinicians in a bind, because we're trained to suppress the feeling. It's called professionalism and behaving a certain way. But what we need to do is that we need to feel have a feeling, identify it, and then manage it, which is a very different story from suppressing it. And that gives you about 50% of the information ah in terms of making your clinical decisions and determination of what to do with suicidal patients that you should not ignore.
00:13:27
Speaker
I think
Suicide Crisis Syndrome
00:13:28
Speaker
that's really good advice to anyone who works with sort of high risk population. Once people have identified that there's something a little bit off, what they're feeling, a shift counter transparentially, what types of steps do you recommend people take and how How has your research sort of informed that? Because I think we feel a lot of things when we're working closely with with patients and some things we can certainly um act on and some, you're right, do need to be.
00:14:05
Speaker
Yes. So um here we come, ah actually, ah to two key concepts in in our research and the results. One is the what suicide crisis syndrome, which is acute suicidal mental state.
00:14:19
Speaker
And the other one is narrative crisis model of suicide, which is a progression of suicidal mental state, ah which in American terms will be described as from low risk to imminent risk.
00:14:32
Speaker
Okay. in European terms, it will be described as intensifying mental state. Okay. two So... On that latter point, the narrative, right?
00:14:43
Speaker
So the person is is altering their sort of autobiographical story of their own future, where suicide becomes more and more part of their future.
00:14:54
Speaker
And I've certainly seen this in my clinical practice, where people may have like an idea that maybe in in some... significant period of time in the future, could be many years, they have an idea that that's how their life ends and that that narrative gets more and more elaborated they spend more time on it.
00:15:13
Speaker
Is that the kind of thing that you're talking about has something to do with their story of themselves? not Not quite, although that could be one of those narratives. The narrative that we're talking about, which is the third stage of the model,
00:15:28
Speaker
a suicidal narrative. And suicide crisis syndrome is the fourth and final stage, most acute stage. It's a narrative ah that ah has no future.
00:15:41
Speaker
Okay, it's before we actually the suicide in the future that a narrative has no future, no acceptable future. Okay. And you you ask people said, Do you see your future? The answer the answer is no.
00:15:54
Speaker
I mean, it's like flat out, they cannot tell. And this theory comes from a ah life narrative theory, which is a psychological theory of, I guess, of our mental state, ah that we all have our own narrative identity, narrative identity theory, which has the beginning, um the course, the present and the future.
00:16:16
Speaker
um And that narrative identity changes. okay and ah becomes ah ah distorts into something which is very specific, also has kind of several components to it, ah starting from achievable goal,
00:16:34
Speaker
a failure to achieve that goal. That means failure to be happy, ah self-degradation, inability to ah connect with people, being rejected, isolating, and then seeing no future.
00:16:47
Speaker
Okay, be feeling like cornered in the dead end. That's the story. they Actually, suicide being part of the future, Okay, as one of the doors that a person can open ah can give them comfort.
00:17:00
Speaker
Okay, but but I seen more ah is actually no future. It's ah that which will lead to the desperation of the suicide crisis syndrome, which is the final stage. And that's actually the closest way to understand it, the simplest way to understand it for clinician is it's a state of um psychotic panic.
00:17:22
Speaker
And it has a combination of affective disturbance, agitation, and also loss of thought control. That's the psychotic component. And at that point, when a person is like that, you cannot change their narrative.
00:17:39
Speaker
You can't. They can't hear you. Is it like a delusional state? Yes, it's a delusional state. It's more like ah it's thought processing state, okay, as well as delusional state. It's actually literally they can't process what you're saying.
00:17:53
Speaker
And what is critical is that um that means that when people are in this stage, psychotherapy is ineffective because they can't hear you, they can't process So I might as well go through the criteria of the syndrome, I think, which I think would be important. Let's go top level. So you've you've developed a model of suicide crisis syndrome, and we'll go through what that is. And that's a real contribution to the field.
00:18:21
Speaker
the way The way I think about and it's probably wrong, But for the purposes of communication, in general medicine, not in psychiatry, we have things like a heart attack.
00:18:35
Speaker
We have a model for that. And it's kind of similar. Like people might have years of worsening plaque disease in their arteries. They might have a little bit of pain here and there.
00:18:46
Speaker
They might have an abnormal EKG. They might be taking medication for high cholesterol. ah But there comes a time when something acute happens and it's biological and the blood vessels close up in the heart or they spasm, the blood supply is cut off, there's damage to the heart tissue.
00:19:04
Speaker
And we call that a myocardial infarction or heart attack. in in a In a way, i you know like I said, it's probably wrong. But i I think of this acute phase as being something like a brain attack.
00:19:17
Speaker
And it should have a medical framework around. We ideally would have a way to treat this acutely. There are
Traits and Vulnerabilities Linked to Suicide Risk
00:19:25
Speaker
some biological treatments that may help. um i'm I'm a ah psychiatrist who offers transcranial magnetic stimulation, which is not indicated for acute suicide right now.
00:19:36
Speaker
But certainly when we treat patients, their suicidality often dissipates within a day or two. And there's some other treatments that have been shown to do that as well, like medications. So I wanted to just frame that idea of suicide crisis syndrome as like a medical event.
00:19:53
Speaker
Well, ah it's a a good analogy. I use a similar analogy, which is actually not myocardial function, and but CHF, congestive heart failure, which is less probably known to most than than heart attack.
00:20:10
Speaker
And the reason i use CHF is that a heart attack is not reversible. You had a heart attack and that's that. CHF is reversible. As is suicidal state when you treat it, i mean, it resolves.
00:20:23
Speaker
And when somebody is in CHF, you give them diuretics, it resolves, they come back. let's say ah if, if, if not particularly severe. ah So, yes, that's, ah ah that's an evolution ah ah of the of the stage from there are certain things that predispose people to developing suicidal state under stress lifetime.
00:20:47
Speaker
that sets long term what we called long term vulnerabilities. And there are many of them. And each of them an increases your risk lifetime to threefold.
00:20:58
Speaker
And the most well known ones, are actually, what people think about this impulsivity, past suicidal behavior, ah mental illness, but actually, probably the most critical one that people don't think about is perfectionism, ah perfectionism, then pessimism,
00:21:17
Speaker
ah Fearlessness. Okay, fearlessness is a critical, it's actually a trait. It's not a quiet capability, it's a trait. And that's why military and policemen and other things ah kill themselves. And the psychopathology that they have actually precedes their combat exposure and violent exposure. It's not the result of it.
00:21:38
Speaker
And you said fearlessness? Fearlessness. Fearlessness. And um the only protective factor, by the way, which is that that works, like, ah is ah moral and religious objections to suicide.
00:21:51
Speaker
Family, ah contrary to popular belief, family ah does not work. I mean, when people are in that state, I mean, they unfortunately jump out of windows with their children, okay, as it happened, you know, at Mount Sinai ah last year.
00:22:08
Speaker
the ah So that's long term. By the way, if there is no stress, And stress comes in particular varieties. These people are not not at risk.
00:22:21
Speaker
And just when a person, ah let's say, who has an unhealthy diet and a young person is not at risk now. But lifetime, they may be.
00:22:32
Speaker
It's a similar situation. And then, you know, stressful life events come, ah which ah come like in five or six varieties really. And that is final romantic rejection, which is associated with suicide within 2448 hours. so So if a person made it for two months, I mean, they they're okay, they're on the other side.
00:22:55
Speaker
ah catastrophic financial failure, ah like severe blow to ego identity has happened to my patient, right because his whole life was shattered and identity was shattered.
00:23:09
Speaker
um Bullying, onset of life-threatening medical illness, ah ah particularly in the elderly, and ah the relentless painful mental illness for a long time, which is actually the hard one of the hardest ones to treat.
00:23:25
Speaker
And so when that happens, I mean, to people who have long-term reability vulnerability, they may develop suicidal narrative. And that is the stage that requires ah intervention and a fairly ah quick intervention.
00:23:41
Speaker
And at that state, before people develop suicide crisis syndrome, they're actually amenable to therapy. They can hear you because they're not in a psychotic state. There's a window of opportunity that's fairly narrow.
00:23:54
Speaker
And it would be like a crisis intervention situation. So in suicide crisis syndrome, ah is they can't hear you, and that needs to be treated medically. okay And usually it takes 24, 48 hours. it's actually sometimes very quickly.
00:24:12
Speaker
okay And then they can hear you So that intervention can be administered in the office or even in the emergency room, definitely in CPAP. Yes, so suicidal narrative is is treatable.
00:24:24
Speaker
And the important part about this, what, you know, as as Grant, you mentioned, is what clinicians think about and what they worry about, and also the relatives, um is that ah people actually talk about it.
00:24:37
Speaker
Okay, people who are suicidal, they're not going to tell you that they're suicidal. And if they tell you that they're suicidal, if this happens, I'm gonna kill myself, it might mean nothing. But what they do talk about is about their suicidal narrative.
00:24:52
Speaker
Okay, they talk about what happened. They talk that they had this goal that they want to make matters and ah you know that they failed the exam and ah their family, immigrant family that was supposed to be paying for them, taking care of them, they cannot show up they face their face there, they can't live.
00:25:08
Speaker
They're
Cognitive vs. Affective Aspects of Suicidal States
00:25:09
Speaker
gonna tell you about this. And, you know, being a nurse is not going to do, they're going to tell you about that and that they're ashamed and they're miserable. That is the components of suicidal narrative that you need to listen to, which are more telling about actually suicidal mind than suicidal ideation.
00:25:27
Speaker
That's the important. I wonder if you could talk about, so at that point when a person has that narrative and it's sort of coming together,
00:25:39
Speaker
what do the interventions there look like as opposed to once they've progressed to the sort crisis syndrome? Well, um our ah i um we hypothesized that suicide crisis syndrome, and we have data for that, by the way, the su suicide crisis syndrome is a matter of days maximum. It resolves within three days, typically, with treatment.
00:26:06
Speaker
with the inpatient or onpatient. So assume that once it is three days. ah The narrative, actually, people are discharged from the hospital with a narrative. They don't just and they're discharged from the hospital with the crisis crisis as result.
00:26:21
Speaker
And ah so if the crisis is resolved, then ah your safety plan, for instance, would work because people can think. Okay, but if it's not resolved, it's not going to work.
00:26:32
Speaker
So ah it lasts weeks, and let's say several weeks typically. And that medication wise, just to make it simple, that actually is a window of opportunity for you to treat somebody with antidepressants if they're depressed, because there is enough time for antidepressant to take effect.
00:26:52
Speaker
The psychotherapeutically, however, the ah the the best, the most dangerous is perception of no future, because that's what goes into suicide crisis syndrome, which is part of entrapment, part it is entrapment and being stuck.
00:27:08
Speaker
and intrabman Entrapment, meaning, excuse me, like the person feels this terrible, terrible psychological, emotional pain, and they feel trapped, that there's no...
00:27:22
Speaker
good options, they see no future. ah So let's let's separate, let's separate that. Okay. And so suicidal narrative is a cognitive state.
00:27:34
Speaker
Okay, it's actually thinking just as Grant, you described it, when ah ah in in your situation, the suicide becomes an an option at the end, but it's a thought. Suicide crisis syndrome is a mental state.
00:27:49
Speaker
It's like, ah it's longer than a panic attack. It's very distinct from a panic attack. People who have panic attacks know the difference. And that needs to be, ah that needs to be ah treated.
00:28:02
Speaker
So ah the narrative, the when people can hear you, ah you restructure, try to restructure the narrative to life narrative, whatever it can be, whatever is the most acute stage, let's say perception of no future is most acute stage.
00:28:17
Speaker
You try to create alternative future that people at least can accept or see or fathom. That's the most critical thing. So this is not entrapment. This is just lack of future expectancies.
00:28:31
Speaker
Entrapment is this. You described actually suicide crisis syndrome and how it feels. Entrapment, the better term for this is frantic hopelessness. It's also contradictory term.
00:28:44
Speaker
It's like one of my patients who, by the way, was suicidal, but never told me and told me only later, like weeks later, or actually months later. So like that, it's like you're in a department store, everybody's like um around you seem to be doing something.
00:29:03
Speaker
And then lights go out. You're all alone and you want to get out and all the doors are locked. So he is a lawyer and that was his state. That's the state, that desperate need to get out of that situation and all the doors are locked.
00:29:19
Speaker
It's a suicide um entrapment. It's actually frantic hopelessness is not a thought. It's an urge. Suicide crisis syndrome, it's an effective feeling. It's an urge. It's not a thought.
00:29:30
Speaker
It's not rational. So what is that word? What kind of hopelessness? Frantic hopelessness. Frantic. Got it. And restlessness. So that's the first criterion, the most important criterion.
00:29:44
Speaker
Then the second criterion that you alluded to ah is um a loss of affective disturbance. which is emotional pain, ah severe anxiety with strange sensations that I mentioned, acute anhedonia, people lose ability to experience pleasure.
00:30:04
Speaker
um And um also, ah but also, also depressive turmoil, ah rapid change in emotions from negative to positive.
00:30:17
Speaker
Okay, you can interpret it to yourself as like somebody is feeling absolutely terrible and let's say suicidal, and then they make an effort, try to establish something as a possible future, then temporarily their mood perks up.
00:30:31
Speaker
Okay, then go back into the into the rabbit hole. That's kind of up and down, up and down. ah By the way, the way to ask about it, since we are now talking in su suicide crisis syndrome, it's like really important ah to interview people correctly about it.
00:30:47
Speaker
So um the first ah question is like somebody comes to the office um or emergency room with a problem, but whatever the problem is, and you listen to the problem. And the question is, now, this problem that you have that brings you to my office today, where you're talking about me today, by the way, if you're a layperson, not psychiatrist, are there new options?
00:31:08
Speaker
and Do you see way out? I mean, that's literally very simple question. And if the answer is no, the first criteria is met. Then the second question is, now, this problem that ah ah that you just told me about that has no exit, is it painful to you?
00:31:24
Speaker
I mean, or does it make you panic? And if the answer is yes, it's like I'm in terrible emotional pain, you clarify that. that created The second criteria is met. The third criterion is loss of cognitive control, criteria B2, which is ah has several components. The most important one is ruminative flooding, meaning ah that you're flooded with negative thoughts, ruminations that ah feel like a rabbit hole to you that you go into and you cannot get out.
00:31:56
Speaker
almost like an OCD experience. Yeah, you can get out you try can and it ah try to climb out you can't and these efforts give you headache and head pressure.
Identifying Suicide Crisis Syndrome
00:32:09
Speaker
And some people feel that the head can explode. That's really important. That's a component of that. And the way to ask about it is that do you feel that you can control your thoughts or your thoughts are controlling you? Okay, and you have headaches?
00:32:24
Speaker
Okay, literally like that. there anything you can change the way you think? You say that's a somatic symptom, meaning the emotion is not expressed in words, but the body is telling us. Right.
00:32:36
Speaker
And then ah the criteria B3 is ah in so over arousal, which is insomnia, agitation, irritability, and hypervigilance, which is being ah kind of hyperattuned to stimuli around you, whatever they may be.
00:32:54
Speaker
And people can't sleep. Most suicides happen at night. And the way to ask about it is that, you know, this problem that it gives you headaches that you can't stop thinking about it.
00:33:06
Speaker
Can you sleep? Okay. And then tell, you know, it comes at night when I'm alone and I can't. And finally, the last one is the acute social withdrawal for people who are normally social. And the way to ask about that is that, does anybody know about this?
00:33:21
Speaker
Okay, have you told anybody about what we're just talking about? And um the reason, by the way, there is a criterion A and for criteria B is that in all our studies, criterion A is the weightiest.
00:33:33
Speaker
and Okay. It has about 50% of the weight. That's the, do you see a future? No. no Do you, uh, this is still better narrative and thought. I see. It is, do you see an option?
00:33:47
Speaker
have you out of your trap, can you can you get out? Is there a way to get out? yeah in In adults, in adolescence, ah and um this has been presented but not published yet, ah the way it is reserved, it's social isolation, okay, that becomes more important because social connectedness is so critical for the adolescence and the, in let's say, frantic hopelessness is less important, but rejection, social isolation.
00:34:17
Speaker
in adolesence So what might ah family members observe? This is kind of how clinicians can operationalize suicide crisis syndrome in a kind of a DSM, diagnostic manual style.
00:34:31
Speaker
What do people who aren't trained observe? And we were talking about this ah sort of idea or myth that some people can seem fine, right? You hear those stories. He seemed fine.
00:34:45
Speaker
every He had everything going for him. um What do people look for who aren't trained? First is, they need ah ah people look for ah is the probably the components of the narrative.
00:35:02
Speaker
Let me give you probably probably the um best, the know the best example, the most concerning example. ah People are very concerned about, let's say children and adolescents, the suicides rates went up.
00:35:14
Speaker
And I actually had to give talks in schools about this. And they say, well, totally normal. Everything was okay. No, it's not okay. There are only two kinds of people, really, of kids who attempt suicide like or die by suicide. ah The first is somebody with relentless mental illness, which started pretty early on when a person was like four and has been in treatment for a long time and nothing seems to be working and whatever medications they may be getting is not helping and be making them worse.
00:35:44
Speaker
And because they're different, they're being bullied. Okay, that's the one kind. And the second kind is a perfectionist, overachieving perfectionist that ah ah is trying to do everything possible ah to be a fine-tuned sports car that his parents wanted to be, regardless of what they're saying.
00:36:04
Speaker
Okay, and that's the second person. And then B plus, okay, could be the stressful life event. Okay, because it means that he is not going to get into Harvard and that's the only thing that is going to make him happy or his family happy because everybody went to harm So it sounds like there's a real narcissistic vulnerability. The person's sense of self and their sense of the world collapses all of a sudden when they face some kind of failure or their idea of how the world is supposed to look is all of a sudden violated, almost like a stool with only one leg. Yeah.
00:36:42
Speaker
Yeah, the stool analogy is a great analogy. And I use it a lot in psychotherapy. It's very concrete. ah ah But help is helpful.
00:36:54
Speaker
So, ah ah you know, you can't ah sit on a stool with one leg because if that leg breaks, i mean, you collapse just like as you described. And there is a theory, which I forgot what it's called, um that the most important things in life are are love, work, play, and you can add spirituality to it.
00:37:15
Speaker
I forgot the name. So these are the four legs of the stool. that the person needs to have, which needs to be reasonably balanced. It's not like 25 25 25 that does not work.
00:37:27
Speaker
ah But you need to have four. And if you ask me, i would probably say it should be like 35 35 or 30 30 2020. Depending where you're But then one if legs the stool breaks,
00:37:39
Speaker
depending of where you at but then one if one legs of the stool breaks okay they had The other three to actually have to keep you going. And so when people maladaptive way of actually coping with stress, let's say at work, is to drop everything and focus more and more on work and on work more and more, harder and harder.
00:38:02
Speaker
And that's the exact worst strategy because you abandon the other three legs and then it doesn't work or something backfires and that's catastrophic blow to ego identity.
00:38:13
Speaker
And the
External Pressures on Youth Mental Health
00:38:14
Speaker
adaptive way is actually rely on the other three legs when that happens. Meaning talk to your love, talk to your friends, i mean, go to temple, whatever whatever works for you, meditate.
00:38:26
Speaker
Right, that's correlated with a resilience. yeah I do think that in some ways, um and maybe we're deviating from this, but when parenting happens,
00:38:39
Speaker
you know, becomes, so I think it's intensified in a lot of ways, particularly with this generation. And there are lots of different thoughts and theories about how to do it best.
00:38:52
Speaker
But it seems like today society rewards people who are hyper specialized, that we have to develop into some sort of like an Olympic athlete or a musical prodigy or something like that. And it is hard. What if you want to go to a good college, right? Right, right.
00:39:11
Speaker
It is hard to really explain to people that a healthy, well-adjusted childhood does not include really excelling um in in those specific ways.
00:39:25
Speaker
Yes, I completely agree. And ah it's a it's very difficult to undo. ah gave i gave a talk, actually, in one of the private schools.
00:39:37
Speaker
ah ah There was a suicide there. And so I actually gave two talks. ah gave ah just ah ah gave identical talks, by the nearly identical.
00:39:48
Speaker
I gave it two times. The first time to the teachers, at four o'clock and the second time to the parents at six o'clock and you know people listened people understood and the teacher said there's nothing we can do because there's so much pressure from the parents I mean for the kids to succeed and you know if they get one one you know question wrong I mean the parent is going to be on top of me we can't stop We absolutely can't stop ah because we're responding to pressure from the parents.
00:40:18
Speaker
And then the parents said, ah we can't stop because we're getting constant email from the school. Okay. And if my kid, you know, looks the other way, i mean, ah he needs a occupational therapy and ADHD assessment.
00:40:30
Speaker
ah And if not, because the school wants to get the the g GPA high, they're going to expel my kids from the school. It's not going to be – it's a tough thing to undo.
00:40:45
Speaker
You know, in a way, I think that's partially a function of kind of a corporate mentality. A lot of these schools, it's almost like HR, and everyone is like so apprehensive about making a mistake.
00:40:59
Speaker
The person who suffers is the kid. Right. Yes. i So I could not agree agree more. um And unfortunately, ah i have to say that um we, meaning mental health professionals, are playing a significant part in this because when parents come to us and say, you know, I think my my son may have learning disability,
00:41:28
Speaker
or ADHD because he's not getting straight A's. So he needs neuropsychological testing. And of course, neuropsychological testing is going to show something which is not up to par with something else.
00:41:40
Speaker
Okay, and that will require cognitive remediation. ah And then it eventually will require stimulus, which would generate anxiety, and that would require SSRIs.
00:41:51
Speaker
And we're off to the races when somebody is on three medications under the pressure. at age 15 and it's ah it's not not a good situation. Well, certainly there's a whole industry in major urban centers like New York where you essentially pay a lot of money to get the the neuropsych testing done and it's targeted for academics.
00:42:14
Speaker
um And I think the impression that the kid gets is that if they're not performing at this high level, they have no value as a human being. And it's it's just, I mean, it's that's a topic for a whole thing. And I think there's all kinds of trauma related to this.
00:42:31
Speaker
I think a lot of the symptoms of the suicide crisis syndrome and the lead up to it that you're describing seem to overlap with things like PTSD in a lot of ways.
Neuroscience of Suicide Crises and Resources
00:42:40
Speaker
I know there's a lot of trauma related to suicide completion and attempts. Well, I have to actually address the overlap because this is a critical issue in terms of including suicide crisis syndrome ah into DSM, which we're working on and we submitted the application and we're going to resubmit it. you've got You've got my vote.
00:43:01
Speaker
yeah and Well, discriminant validity, okay which is the fact that ah actually SES is different from other disorders, including PTSD okay in and depression, is critical.
00:43:15
Speaker
And we actually just wrote two papers on two different samples that it is different. Okay. And transdiagnostic. Yeah. There's overlap in the DSM. it's The term is polythetic, meaning there are categories that overlap and there's a lot of redundancy. I think we need a better system that's based on biology and the brain.
00:43:35
Speaker
i did want to ask briefly if there is any sort of what is the neuroscience here? um which is, you know, we're just beginning to really understand neuroscience, I think, but... the ah We published a paper, ah Suicide Crisis Syndrome, What to Test Next.
00:43:54
Speaker
ah And there, phenomenologically, there are four neurotransmitter systems involved. The ah first one is ah arousal, and it is GABA, and that's why benzodiazepines work.
00:44:08
Speaker
The second one is loss of cognitive control, which is dopamine. That's why antipsychotics work. The third one is emotional pain. okay That's why opiates work, including ketamine, because it's an opiate.
00:44:24
Speaker
That's why it works. And the last one, possibly oxytocin, and okay, which is social connectedness. um But I haven't seen yet ah that it's available, by the way, as a pitocin to for to induce actually contractions in labor.
00:44:41
Speaker
ah And ah some people use it clinically, but I haven't seen that being effective. But the first three are Yeah, there's some studies of intranasal oxytocin and lithium reduces suicidality and some other drugs.
00:44:57
Speaker
Like I said, I've seen patients with TMS, their suicide, even people with chronic suicide from their preteens has disappeared in a week, which we don't quite know what's happening.
00:45:08
Speaker
um Though I think of that more from the level of brain networks. So if you see these sudden switches in mental state, um it's likely you know that there's switches in the network, certain parts of executive function coming offline, for example, if you can no longer talk to the person and connect with them.
00:45:28
Speaker
So we're coming into the last few minutes. Farah, is there any, do you have any burning question or topic? I think. thought it was great to bring up the role of the family in the academic environment.
00:45:41
Speaker
I mean, these are our huge contributions and and it's a really exciting time. I think to be a psychiatrist as a result, right? We're learning that there's so much more that we can do in the field you know, is making great strides thanks to people like you guys. But I am wondering where people can find out more about the work that you're doing, how they could i either follow along or i know you have the Bipolar Family Center. So.
00:46:14
Speaker
Well, um if If people kind of just Google my name, ah ah what's going to come up is Balenciaga Suicide Research Prevention Lab, then Gallenka Family Center for Bipolar Disorder, and now Family Center for suicide Suicide Prevention, which we just opened recently.
00:46:35
Speaker
which uses this system. okay We actually stage suicidal process and treat accordingly to the stages. It opened like ah two or three months ago, so it's a relatively recent. Congratulations.
00:46:48
Speaker
Thank you. And each of these sites... each of these sites has links to various appearances. And probably my most so public statement to date is the interview with Eileen Kelly ah on Go Mental.
00:47:06
Speaker
ah And it it's ah but was a really good interview. I think it has about 250,000 views now. Okay, so it's probably, this is where lay people kind of find me.
00:47:19
Speaker
And then they contact me with questions and emails and things like that, which I get. mom and dad yeah Well, thanks so much for joining us, Dr. Glinker. It was really a learning experience. And again, thank you for your good work here. Thank you for your interest.
00:47:34
Speaker
It's a pleasure and good luck to you. Thanks. Remember, the Doorknob Comments podcast is not medical advice. If you may be in need of professional assistance, please seek consultation without delay.