Received: 7 September 2018 | Revised: 31 October 2018 | Accepted: 4 December 2018

DOI: 10.1002/jclp.22743

REVIEW ARTICLE

The necessity, validity, and clinical utility

of a new diagnostic entity: Acute suicidal
affective disturbance

Megan L. Rogers1 | Carol Chu2 | Thomas Joiner1

1
Department of Psychology, Florida State
University, Tallahassee, Florida
2
Department of Psychology, Harvard
University, Cambridge, Massachusetts
Correspondence
Thomas Joiner, Department of Psychology,
Florida State University, 1107 West Call St
Tallahassee, FL 32306.
Email: joiner@psy.fsu.edu
Funding information
National Institute of Mental Health, Grant/
Award Number: T32 MH09331104; U.S.
Department of Defense, Grant/Award
Number: W81XWH‐10‐2‐0181
Abstract
Objective: Here we argue for the necessity, validity, and
clinical utility of a new diagnostic entity, acute suicidal affective
disturbance (ASAD).
Method: We expand on the conceptual, clinical, and
practical rationale for ASAD, propose its defining features,
describe research results to date, and suggest avenues for
future research.
Results: There is accruing evidence for the existence of a
previously unclassified, rapid‐onset mood disturbance that
geometrically escalates and regularly results in life‐threa-
tening behavior.
Conclusions: ASAD research may not only improve the
field’s understanding of suicidal behavior but also enhance
clinical effectiveness and save lives.

KEYWORDS
acute suicidal affective disturbance, diagnosis, suicide

The first step in wisdom is to know the things themselves… objects are distinguished and known by
classifying them methodically and giving them appropriate names. (Carolius Linnaeus).

Consider the following scenario, based on actual cases encountered by the senior author: an individual is diagnosed
with a nonmood disorder psychiatric condition (e.g., schizophrenia) and admitted to inpatient psychiatry. During
hospitalization, mood disorder symptoms and suicide risk are regularly assessed and viewed as minimal. The patient’s chart
indicated the occurrence of a suicide attempt approximately 4 years before. However, the circumstances surrounding this
attempt were not documented, and unbeknownst to unit clinicians and unreported by the patient, a past history of rapid‐
onset, intense suicidal crises occurred about 5 years previously. The condition is aggressively treated and clear
improvement is observed. The individual is, thus, discharged; approximately 18 hr postdischarge, suicidality again
intensifies dramatically, culminating in the individual’s death by suicide. The primary condition had not worsened.

J. Clin. Psychol. 2019;75:999–1010. wileyonlinelibrary.com/journal/jclp © 2019 Wiley Periodicals, Inc. | 999

1000 | ROGERS ET AL.

Scenarios like this involving precipitous increases in suicidality (whether occurring posthospitalization or not) in
nonmood disordered patients, although not the norm, nevertheless represent a sizable minority of suicide deaths. Is
it plausible to attribute a catastrophic outcome like suicide to a condition that had improved, and that had not
subsequently worsened? Is it possible that an ongoing mood disorder was to blame when mood pathology had been
routinely assessed and ruled out? Is it reasonable to leave undiagnosed a condition that leads to death?
Here, we contend that the answer to these questions is “no,” and argue for the necessity, validity, and clinical
utility of a new suicide‐specific diagnostic entity, acute suicidal affective disturbance (ASAD; Tucker, Michaels,
Rogers, Wingate, & Joiner, 2016; cf. Aleman & Denys, 2014; American Psychiatric Association [APA], 2013). Should
clinicians in the case example above have been aware of the possible presence of ASAD—in addition to the patient’s
documented suicide attempt history—they may have been alert to the possibility of a rapid recurrence
postdischarge and, thus, might have intensified safety measures that may have mitigated suicide risk to a nonlethal
level. Importantly, entry of a new entity into prominent nomenclatures is unlikely, absent both pressing clinical
need and a robust scientific basis. Below we expand on the conceptual, clinical, and practical rationale for a new
diagnostic entity, propose defining features, compare ASAD to other proposed suicide‐specific entities, describe
research results to date, and highlight areas in need of future research.

1 | CONC EPT UAL , C LINICA L, A ND P RA CTICA L RATION ALE FOR A N EW

DIAG NO S T I C E N TI TY

Although, suicidality is included at the symptom level in major depressive episodes and borderline personality
disorder, these disorders are not defined by it and, moreover, relatively rarely result in death by suicide by
themselves. For instance, suicide rates are estimated to range from 3.8% to 7.8% for mood disorders (Nordentoft,
Mortensen, & Pedersen, 2011) and 8% to 10% for borderline personality disorder (Paris, 2002). Anorexia nervosa
and schizophrenia, on the other hand, do not include suicidality as a diagnostic consideration at all, despite being
two of the five most lethal psychiatric conditions (i.e., highest death by suicide rate) per capita (see Chesney,
Goodwin, & Fazel, 2014). Thus, suicide does not appear to be central to existing conditions—odd, it could be argued,
given the lethal outcome.
This state of affairs leaves only two options: (a) the status quo, in which catastrophic outcomes are left
diagnostically unexplained—a rarity in healthcare when an illness of some sort is clearly involved (unlike in
accidents, for example); or (b) the designation of a suicide‐specific diagnostic entity. To address this concern,
suicidal behavior disorder (SBD) was included as a “Condition for Further Study” in the Diagnostic and Statistical
Manual of Mental Disorders (DSM‐5; APA, 2013). The criteria for SBD essentially equate to a suicide attempt in the
past 2 years; thus, suicidal behavior is viewed as an outcome without characterizing the phenomenology of a
suicidal crisis. Knowledge of past suicidal behavior is clinically informative and there are substantial benefits of
documenting and classifying suicidal behavior (Oquendo & Baca‐Garcia, 2014). However, past suicidal behavior
provides little insight into whether and when an individual may attempt suicide in the future (Glenn & Nock, 2014;
Ribeiro et al., 2016). A focus on acute suicidal symptoms may provide additional clinical insight into suicide risk
assessment and management; the importance of capturing acuity is accentuated by the heightened suicide rates
following discharge from inpatient psychiatry (Chung et al., 2017). We assert that a suicide‐specific diagnostic
entity should reflect not only acuity but also parsimoniously represent empirically identified warning signs for
suicide.
Beyond capturing all relevant psychopathology in a nosology, Oquendo and Baca‐Garcia (2014) highlight
several compelling arguments for a suicide‐specific entity in the DSM. Inclusion in nomenclature provides structure
for classification in medical records—clinical settings with standardized suicide risk documentation may already
ensure that risk is recorded, but this may not be the practice in less structured environments, where data about
suicide risk may be lost or not included during hand‐offs and in discharge paperwork (Malone, Szanto, Corbitt, &
ROGERS ET AL. | 1001

Mann, 1995). This is particularly important in the case of ASAD, where symptom recurrence may be likely and can
lead to death. Many clinicians also tend to rely on the assessment of self‐injurious thoughts and behaviors to
determine current suicide risk. However, relatively few focus on acute configurations of suicide risk (i.e., features
signaling imminent risk; Glenn & Nock, 2014); ASAD may help fill that gap. Further, conditions that result in death
but lack a diagnostic label may lead to misclassification of cause of death in registries. Finally, despite concerns that
a suicide‐specific diagnosis may facilitate lawsuits, it may actually enhance patient care and mitigate clinician
liability (Joiner, Simpson, Rogers, Stanley, & Galynker, 2018).

2 | DEFINING F EATU RES OF A S AD

ASAD is thought to be characterized by drastic spikes in suicidality, and as such, is hypothesized to be a time‐
limited arousal state that abates over time through appropriate management (e.g., B. Stanley & Brown, 2012).
Based on empirical work on acute suicide risk, prominent theories of suicide, and clinical and consulting experience,
we conjecture that the key features of ASAD include:

(A) A drastic increase in suicidal intent over the course of hours or days (not weeks or months);
(B) Marked social alienation (e.g., social withdrawal, perceived liability on others) and/or self‐alienation (e.g., self‐
hatred, perceptions that one’s self is an onerous burden);
(C) Perceptions that the above criteria are hopelessly intractable;
(D) Two or more manifestations of overarousal (agitation, irritability, insomnia, nightmares).

Further, the disturbance cannot be wholly accounted for by another condition, such as a mood disorder or substance
use. Individuals who experience all four criteria within a time frame of hours or days are considered to meet criteria for an
ASAD diagnosis; those experiencing these symptoms in the past week meet criteria for a current ASAD episode.

2.1 | Theoretical context

2.1.1 | Suicidal intent
Suicidal intent, characterized by explicit intentions and plans to make a suicide attempt, has been associated with
an increased likelihood of death by suicide (Nock & Kessler, 2006). Importantly, suicidal intent and desire are not
synonymous and vary independently of one another (Van Orden et al., 2010); indeed, suicidal intent and resolved
plans and preparations signal more imminent risk for suicide than suicidal desire (Joiner et al., 2003). Although little
research has explicitly examined the trajectory of suicidal intent over time, there is evidence to suggest that, at
least in some individuals, suicidal intent may rapidly escalate over time. For instance, individuals discharging from
inpatient psychiatric units, who presumably have been thoroughly assessed for suicide risk before discharge, have
considerably high suicide rates, particularly in the days and weeks following discharge (Chung et al., 2017). One
possibility is that these decedents failed to disclose continuing suicidal thoughts and urges; another is that suicidal
intent returned rapidly following discharge. Another line of research suggests that some individuals engage in
suicidal actions without spending much time contemplating or planning for suicide (Rimkeviciene, O’Gorman, & De
Leo, 2015). One study examining the hours preceding suicidal behavior found that 42% progressed from first
contemplation of suicide to a suicide attempt within 3 hr; likewise, 68% progressed from first consideration of a
plan and 85% made the decision to act within this time frame (Bagge, Littlefield, & Lee, 2013). Although these
individuals are often described as “impulsive” suicide attempters (May & Klonsky, 2016), associations between
suicidal behavior and impulsivity are small (Anestis, Soberay, Gutierrez, Hernández, & Joiner, 2014; May & Klonsky,
2016). Another possibility is that some of these individuals are experiencing rapidly intensifying increases in
suicidal intent that culminate in suicidal behavior.
1002 | ROGERS ET AL.

2.1.2 | Social alienation

Social isolation, comprising loneliness, social withdrawal, and a lack of social support among other facets, is one of
the most reliably documented predictors of suicidal ideation, attempts, and death by suicide across samples with
varying ages, nationalities, and clinical features (e.g., Duberstein et al., 2004). Psychological autopsy studies have
demonstrated that in the days and weeks leading up to an individual’s death by suicide, suicide decedents
frequently become more socially withdrawn, less talkative, and lose interest in social activities (Appleby, Cooper,
Amos, & Faragher, 1999). Likewise, in‐person proximity to others has been associated with changes in suicidal
ideation in real‐time (Husky et al., 2017). The three‐step theory (Klonsky & May, 2015) specifically posits that
social connectedness may serve as a protective factor against active suicidal desire. Similarly, the interpersonal
theory of suicide (Van Orden et al., 2010) conceptualizes thwarted belongingness (loneliness and a perceived
absence of reciprocal relationships) and perceived burdensomeness (the belief that one’s death is worth more
than one’s life) as multidimensional latent constructs that characterize internal perceptions of social
disconnectedness and lead to suicidal desire. Each of these constructs has accumulated support as a correlate
of suicidal thoughts and behaviors (see Chu et al., 2017, for meta‐analysis). Altogether, social isolation—whether
in the form of actual withdrawal from others or perceived social connection—is a pernicious risk factor for
suicide.

2.1.3 | Self‐alienation
Major conceptualizations of suicide highlight some form of intractable agony. For instance, theories on psychache
(Shneidman, 1996), hopelessness (Beck, Steer, Kovacs, & Garrison, 1985), escape (Baumeister, 1990), and the
three‐step theory (Klonsky & May, 2015) emphasize intractability and psychological pain; however, the specifics of
agony are not described in detail. Indeed, Klonsky and May (2015) argue that pain may arise from myriad sources,
rather than any one type of aversive thought, emotion, or experience. The integrated motivational–volitional model
of suicidal behavior (O’Connor, 2011) and the interpersonal theory of suicide (Van Orden et al., 2010) specifically
describe the nature of psychological suffering (i.e., defeat, entrapment, thwarted belongingness, perceived
burdensomeness). Likewise, some have identified acute, high‐intensity states of negative affect serving as a trigger
for suicidal behavior (Hendin, Al Jurdi, Houck, Hughes, & Turner, 2010).
In addition to psychological pain, ample literature has pointed to self‐disgust, self‐hatred, and inwardly
directed hostility as indicators of suicide risk. Self‐disgust elicits a desire to withdraw from one’s revulsive
attributes and feelings of negativity or hatred toward the self. It may also trigger an active desire to physically
avoid or destroy the object of revulsion (in this case, the self; Moll et al., 2005). Disgust with the self has also
been linked to a variety of negative self‐views, including self‐hatred and self‐criticism (Gilbert, Clarke, Hempel,
Miles, & Irons, 2004; Powell, Overton, & Simpson, 2014), each of which have been robustly associated with
self‐injurious thoughts and behaviors (Hendin, Maltsberger, Haas, Szanto, & Rabinowicz, 2004). Self‐hatred,
composed of low self‐esteem, self‐blame/shame, and agitation, is also a defining feature of perceived
burdensomeness (Van Orden et al., 2010). Accordingly, repulsion or hatred of the self may contribute to
feelings of perceived burdensomeness and suicidality.

2.1.4 | Hopelessness
Hopelessness is an oft‐cited risk factor for suicidal ideation, attempts, and death by suicide, and has been included
in several theoretical accounts of suicide, including Beck’s hopelessness theory (Beck et al., 1985), the interpersonal
theory of suicide (Van Orden et al., 2010), and the three‐step theory (Klonsky & May, 2015). Together, these
theories converge to support the idea that perceived intractability of psychological pain, social alienation, and self‐
alienation may contribute to, at a minimum, desire for suicide.
ROGERS ET AL. | 1003

2.1.5 | Overarousal
Empirical support also exists for overarousal states, including agitation (Busch, Fawcett, & Jacobs, 2003),
irritability (Trivedi et al., 2011), and sleep disturbances (Pigeon, Pinquart, & Conner, 2012), preceding
suicidal behavior. Agitation has been observed among suicide decedents in the week before their deaths
(Busch et al., 2003) and has predicted death by suicide within a 1‐year follow‐up period (Fawcett et al., 1990).
Similarly, irritability has been linked to increased suicide risk (Trivedi et al., 2011), especially among those
who are experiencing mixed episodes (Popovic et al., 2015). Sleep disturbances are also frequently observed
in suicide decedents before their deaths (Busch et al., 2003) and have predicted suicidal ideation, attempts,
and death by suicide at 1‐year follow‐up (Fawcett et al., 1990; Wojnar et al., 2009). Overarousal may precede
suicidal actions because killing is a daunting act that cannot be enacted without high states of energy and
arousal (Joiner & Stanley, 2016); suicide involves dying too, and the prospect of death is fearsome and
alarming, thus activating and arousing (Joiner, Hom, Hagan, & Silva, 2016). Indeed, this proposition has been
supported across several studies examining interactions between overarousal and capability for suicide in
predicting suicide risk and behaviors (Ribeiro, Silva, & Joiner, 2014; Ribeiro, Yen, Joiner, & Siegler, 2015).
Overall, ASAD criteria capture the intersection of these theories well and may represent a distinct class of
individuals whose affective disturbances result in a deadly spike of suicidality. Below we describe research findings
to date, as well as a program of research that will be necessary to further support or falsify these claims.

2.2 | Research to date on the construct validity of ASAD

The structure of ASAD has been examined in samples of at‐risk young adults (Tucker et al., 2016) and
psychiatric outpatients and inpatients (Rogers, Chiurliza, et al., 2017; I. H. Stanley, Rufino, Rogers, Ellis, &
Joiner, 2016). These studies support the unidimensionality and cohesion of ASAD symptoms. For instance,
Tucker et al. (2016) first examined ASAD in undergraduate students with a history of suicidality, using an
instrument specifically designed to measure worst‐point ASAD symptoms. In this study, ASAD demonstrated
a strong one‐factor solution. I. H. Stanley et al. (2016) and Rogers et al. (2017) replicated and extended these
findings considerably in large samples of psychiatric outpatients and inpatients, using proxy items and
measures that tap into the ASAD construct and the use of confirmatory factor analyses. These samples
similarly yielded evidence of convergent and discriminant validity, with expected and nonredundant
associations between ASAD and other risk factors, personality correlates, and existing psychological
disorders (Rogers, Chiurliza, et al., 2017; Rogers et al., 2016). Finally, ASAD symptom severity differentiated
individuals who have attempted suicide from those who have thought about suicide across all samples and
was associated with lifetime suicide attempts beyond depression symptoms and other psychiatric disorders
(Rogers, Chiurliza, et al., 2017).
Likewise, in an initial effort to examine the cohesion of ASAD, as well as its divergence from symptoms of
anxiety and depression, Rogers, Hom, and Joiner, (under review) conducted a network analysis in a sample of
psychiatric inpatients to evaluate whether current ASAD symptoms comprised a psychopathological network
distinct from current anxiety and depression symptoms. Network analyses revealed three distinct clusters of
symptoms, corresponding to ASAD, anxiety, and depression symptoms. Of note, ASAD symptoms
demonstrated not only strong associations with each other but relatively weaker associations with
symptoms of anxiety and depression, supporting their distinctiveness. Though preliminary due to reliance on
a cross‐sectional design, these findings indicate that ASAD may represent a construct distinct from anxiety
and depression despite similar symptom criteria (e.g., agitation, sleep disturbances), underscoring its
potential diagnostic value and the possibility that symptoms manifest differently within the context of ASAD
episodes than in other forms of psychopathology. Together, initial studies support the construct validity of
ASAD, though with some crucial limitations.
1004 | ROGERS ET AL.

2.3 | Other proposed suicide‐specific diagnostic entities

As noted previously, other independently developed suicide‐specific diagnostic entities have been developed.
However, each differs conceptually from ASAD. First, we have already discussed differences between ASAD and
SBD, such that ASAD captures the acute phenomenology of a suicidal crisis, whereas SBD denotes the occurrence
of a suicide attempt within the preceding 2 years. In contrast, suicide crisis syndrome (SCS; Galynker et al., 2017)
and ASAD have several overlapping criteria, including an acute and rapid‐onset course of relatively short duration,
aspects of overarousal, hopelessness, and social withdrawal (see Rogers, Galynker, Yaseen, Defazio, & Joiner, 2017,
for a detailed comparison). However, a critical distinction between the two conditions lies in the centrality of
suicidal ideation/intent. Specifically, suicidal intent is a core feature of ASAD, but explicit suicidal ideation is not
required in SCS. An intriguing possibility is that SCS and ASAD represent the same illness, though at different
points in the course of illness of over time, with ASAD representing the end‐stage. Future work should compare the
nature of these conditions, especially in understanding distinctions between ASAD, SBD, and SCS (and indeed,
whether the latter and ASAD are characterizations of the same overarching condition).

3 | F U T U R E A R E A S O F RE S E A R C H

Future work validating a suicide‐specific diagnostic entity is needed in several domains. In a classic paper, Robins
and Guze (1970) emphasized five criteria necessary for validation of psychopathological diagnostic entities: clinical
description (defining features, prevalence, course, and precipitating factors), laboratory study (physiological,
anatomical, and psychological test findings), exclusion of other disorders (differentiation from already‐existing
conditions), study of course of illness (allowing for understanding of ASAD over time), and family history research
(examination of hereditary and environmental contributions). Further, antecedent, concurrent, and predictive
validation must be present (Regier, Kuhl, & Kupfer, 2013).

3.1 | Clinical description

First, although most studies to date have examined ASAD’s clinical presentation, additional studies investigating
the typical onset and time course of ASAD (particularly as it pertains to the interrelatedness of ASAD symptoms),
precipitating biopsychosocial factors, and differences across sociodemographic groups are needed. For instance,
some evidence suggests that negative thought patterns and suicide‐specific rumination may contribute to the
occurrence and increased the likelihood of recurrence of an ASAD episode (Rogers & Joiner, 2018; Rogers et al.,
2018). It may also be worth examining whether ASAD features differ, dependent on whether suicidal desires are
expressed in an operant (i.e., functioning to affect the environment) or respondent (i.e., elicited by preceding events
or situations) manner (Linehan, 1993)—or conversely, whether desires are expressed at all. In addition, some
features of ASAD (e.g., social alienation) have been examined using experimental methods; these studies have
revealed interactions between social alienation and capability for suicide in predicting laboratory proxies for self‐
injurious behavior (Hames et al., 2017). Ethical experimental designs assessing other ASAD components (e.g., self‐
alienation, overarousal) may further clarify the clinical picture. Similarly, it will be important to differentiate rapid
surges of suicidal intent leading to suicidal behavior from impulsive behavior more generally, consistent with
evidence that suicide is not linked directly to impulsivity (Anestis et al., 2014). It will also be worth establishing that
ASAD represents a surge in suicidal intent rather than simply increased disclosure of already‐present intent, given
that suicidality may be underreported in some high‐risk populations (e.g., Vannoy et al., 2016) and that issues
related to accurate disclosure of suicidal intent are critical to the clinical utility of ASAD. In particular, the use of
implicit measures, behavioral observations, and/or discussions with close others (e.g., family members) to assess
suicide risk, or the use of supplemental, less face valid, assessments of ASAD (pending the determination of such
features in future research) may be beneficial.
ROGERS ET AL. | 1005

3.2 | Laboratory study

Biological studies at all levels of analysis may also be informative. Consistent and reliable findings regarding the
biological correlates of suicide risk and many psychiatric disorders have been elusive (Ernst, Mechawar, & Turecki,
2009). Nevertheless, when consistent with a defined clinical picture, laboratory studies add considerable value. For
example, a review of neuropsychological and neuroimaging studies found that (a) suicide attempters showed
greater attention to specific negative emotional stimuli, impaired decision‐making and problem‐solving, and
reduced verbal fluency; and (b) the ventrolateral orbital, dorsomedial and dorsolateral prefrontal cortices (dPFC),
anterior cingulate gyrus, and the amygdala may play a role in facilitating the development of suicidal crises and
actions (Jollant, Lawrence, Olié, Guillaume, & Courtet, 2011). More specifically, recent studies examining the
potential pathophysiological substrates of suicide have found evidence for disrupted activation and neuronal
impairments (i.e., low metabolic N‐acetylaspartate; Jollant, Near, Turecki, & Richard‐Devantoy, 2017) in the right
dPFC of individuals with a history of suicide attempts (Jollant et al., 2008; Sublette et al., 2013). Among individuals
who have attempted suicide, disrupted dPFC functioning and connectivity with other cortical regions may be
associated with altered sensitivity to the social environment and impaired decision‐making, difficulties regulating
negative emotions and solving problems, and facilitation of behaviors in an emotional context (Jollant et al., 2017).
Consistent with behavioral manifestations of ASAD, these dPFC‐related impairments may contribute to increased
social‐ and self‐alienation and perceptions that feelings of pain and alienation are intractable. Notably, these studies
suggest the potential for examination of biologically driven processes associated with ASAD.

3.3 | Delimitation from other disorders

As similar clinical features are often shared across disorders (APA, 2013), further research must ensure that the
key ASAD features are not better accounted for by other conditions. ASAD is not viewed as a consequence of
worsening mood symptoms or substance use. Indeed, some preliminary evidence, as noted above, suggests that
ASAD is distinct from various disorders (Rogers, Chiurliza, et al., 2017) and symptoms of anxiety and depression
(Rogers et al., under review). Future work, however, is needed to replicate and extend these findings in distinct
samples from separate groups of investigators, as well as examining associations between ASAD and other
symptom clusters (e.g., posttraumatic stress disorder, borderline personality disorder, substance use disorders) to
establish ASAD’s distinct contributions.

3.4 | Course of illness

All studies thus far have been cross‐sectional, precluding examination of etiology and course. Prospective studies of
ASAD are essential not only given the time‐limited nature of ASAD, the likelihood that episodes may recur, and
limited data to date on prognosis, but also to determine if patients are suffering from some other already‐defined
disorder that could better account for the original clinical picture (coinciding with our discussion of delimitation
from other disorders, above). Repeated follow‐up assessments and methodologies, such as ecological momentary
assessment (Kleiman & Nock, 2017) or timeline follow‐back methodology (Bagge et al., 2013), are well‐suited for
short‐term prospective studies on ASAD. Further, subsequent to the identification of patients who have
experienced an ASAD episode, long‐term follow‐up should examine the course and prognosis of ASAD.

3.5 | Family study

Finally, although suicide is known to be more prevalent among family members of suicide decedents (Qin, Agerbo, &
Mortensen, 2002), ASAD has not been examined using familial frameworks. Future research examining the occurrence
of ASAD among close relatives to better understand hereditary and environmental contributions to suicidal behavior is
1006 | ROGERS ET AL.

needed. Importantly, this area of research need not be separate from the other phases of establishing diagnostic
validity; these phases should interact with one another to provide further refinement of ASAD.

4 | CATE GORICAL V ERSUS D IMENSIONA L A PP ROA CH ES TO

PSY CH O PAT HOLO GY

None of the foregoing provides definitive evidence for ASAD, though the evidence is accruing that it is a valid and
relevant entity. However, it could be argued that the addition of ASAD to the nomenclature stands in contrast to
dimensional approaches to psychopathology (e.g., Hierarchical Taxonomy of Psychopathology [HiTOP]). Traditional
taxonomies, like the DSM, characterize psychopathology categorically rather than as on a continuum; this approach
may exhibit limited reliability, high heterogeneity, and high rates of comorbidity between disorders (Kotov et al.,
2017). It should be noted, however, that even if death by suicide and, for example, moderate suicidal ideation
represent differing locations on the same underlying continuum, death is categorical, and thus there may be
pragmatic benefits in characterizing the lethal or near‐lethal area of the continuum as having its own
distinctiveness. Moreover, it is surely possible that the suicidality spectrum is a hybrid of the categorical and
dimensional, with a true break occurring at the extreme severe end of the spectrum and with continua operative
with each side of the break. Waller and Meehl (1998) repeatedly noted their view that this was the case with all or
almost all phenomena in nature that display categorical qualities.
Nevertheless, given these new directions in the field, it is worth exploring ASAD symptoms dimensionally as a
spectrum of co‐occurring symptoms, rather than as a diagnostic category. For instance, future studies investigating
the nature and diagnostic relevance of ASAD would benefit from the use of multiple indicators across different
units of analysis and incorporating constructs from the NIMH’s Research Domain Criteria (RDoC) endeavor
(Simmons & Quinn, 2014). Indeed, several RDoC domains (e.g., negative and positive valence, perception and
understanding of others, and arousal systems) have been examined in relation to suicide risk more generally (see
Glenn, Cha, Kleiman, & Nock, 2017; for review), with statistically significant, yet small, weighted effect sizes (Glenn
et al., 2018). Moreover, several components of ASAD overlap with negative valence, cognitive, social processes, and
arousal and regulatory systems. To emerge as a practical alternative to DSM‐based diagnoses, though, others have
argued that these systems will need to prove: (a) reasonable applicability in ordinary clinical practice and among
different categories of professionals; and (b) to be more clinically useful in guiding treatment decisions and
predicting outcomes (Maj, 2018), evidence that has not yet accrued.
With regard to the study of suicide, at least three distinct research teams have independently identified
subgroups at serious risk of suicide; these subgroups tend to be characterized by ASAD symptoms. In addition to
our team’s research on ASAD and separate research on SCS (Galynker et al., 2017), the Army STARRs project
(Schoenbaum et al., 2014) and Witte, Holm‐Denoma, Zuromski, Gauthier, and Ruscio (2017) have reported on
severe subgroups that would likely satisfy ASAD criteria. In the latter example, there is evidence for a categorically
distinct subgroup. The taxon’s two primary indicators were suicidal intent and insomnia, which overlap considerably
with ASAD criteria. Accordingly, categorical/taxometric and dimensional approaches are likely complementary, and
future research utilizing both categorical and dimensional approaches to understanding suicide, as well as suicide‐
specific entities, like ASAD, is worthwhile.

5 | CONC LU SION

This paper’s epigraph references Linnaeus, but we do not claim that the ASAD conjecture is Linnaean in profundity
or scope. Although much research is needed to validate ASAD as a distinct clinical entity, we believe that ASAD is
discernible from and nonredundant with existing clinical entities, and that it is clinically useful. ASAD deserves
ROGERS ET AL. | 1007

consideration in future versions of prominent nosologies and, far from encouraging continued prejudice and stigma,
it will further understanding and prevention of states of mind that culminate in death by suicide.

A C K N O W L E D GM E N T S

This article was supported, in part, by grants awarded to Florida State University by the Department of Defense
(W81XWH‐10‐2‐0181). The Department of Defense had no further role in the study design; in the collection,
analysis, and interpretation of data; in the writing of the report; and in the decision to submit the paper for
publication. The content of this paper is solely the responsibility of the authors and the views and opinions
expressed do not necessarily represent those of the Department of Defense or the United States Government.
This research was also supported, in part, by a grant from the National Institute of Mental Health (T32
MH093311‐04).

OR CID

Megan L. Rogers http://orcid.org/0000-0002-4969-7035

Thomas Joiner http://orcid.org/0000-0001-6798-9085

REFERENC ES

Aleman, A., & Denys, D. (2014). Mental health: A road map for suicide research and prevention. Nature, 509, 421–423.
American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM‐5) (5th ed.). Author.
Anestis, M. D., Soberay, K. A., Gutierrez, P. M., Hernández, T. D., & Joiner, T. E. (2014). Reconsidering the link between
impulsivity and suicidal behavior. Personality and Social Psychology Review, 18, 366–386. https://doi.org/10.1177/
1088868314535988
Appleby, L., Cooper, J., Amos, T., & Faragher, B. (1999). Psychological autopsy study of suicides by people aged under 35.
The British Journal of Psychiatry, 175, 168–174.
Bagge, C. L., Littlefield, A. K., & Lee, H. J. (2013). Correlates of proximal premeditation among recently hospitalized suicide
attempters. Journal of Affective Disorders, 150, 559–564.
Baumeister, R. F. (1990). Suicide as escape from self. Psychological Review, 97, 90–113.
Beck, A. T., Steer, R. A., Kovacs, M., & Garrison, B. (1985). Hopelessness and eventual suicide: A 10‐year prospective study
of patients hospitalized with suicidal ideation. The American Journal of Psychiatry, 142, 559–563.
Busch, K. A., Fawcett, J., & Jacobs, D. G. (2003). Clinical correlates of inpatient suicide. Journal of Clinical Psychiatry, 64,
14–19. https://doi.org/10.4088/JCP.v64n0105
Chesney, E., Goodwin, G. M., & Fazel, S. (2014). Risks of all‐cause and suicide mortality in mental disorders: A meta‐review.
World Psychiatry, 13, 153–160.
Chu, C., Buchman‐Schmitt, J. M., Stanley, I. H., Hom, M. A., Tucker, R. P., Hagan, C. R., … Joiner, T. E. (2017). The
interpersonal theory of suicide: A systematic review and meta‐analysis of a decade of cross‐national research.
Psychological Bulletin, 143, 1313–1345.
Chung, D. T., Ryan, C. J., Hadzi‐Pavlovic, D., Singh, S. P., Stanton, C., & Large, M. M. (2017). Suicide rates after discharge
from psychiatric facilities: A systematic review and meta‐analysis. JAMA Psychiatry, 74, 694. https://doi.org/10.1001/
jamapsychiatry.2017.1044
Duberstein, P. R., Conwell, Y., Conner, K. R., Eberly, S., Evinger, J. S., & Caine, E. D. (2004). Poor social integration and
suicide: Fact or artifact? A case‐control study. Psychological Medicine, 34, 1331–1337. https://doi.org/10.1017/
S0033291704002600
Ernst, C., Mechawar, N., & Turecki, G. (2009). Suicide neurobiology. Progress in Neurobiology, 89, 315–333. https://doi.org/
10.1016/j.pneurobio.2009.09.001
Fawcett, J., Scheftner, W. A., Fogg, L., Clark, D. C., Young, M. A., Hedeker, D., & Gibbons, R. (1990). Time‐related predictors
of suicide in major affective disorder. The American Journal of Psychiatry, 147, 1189–1194.
Galynker, I., Yaseen, Z. S., Cohen, A., Benhamou, O., Hawes, M., & Briggs, J. (2017). Prediction of suicidal behavior in high
risk psychiatric patients using an assessment of acute suicidal state: The suicide crisis inventory. Depression and Anxiety,
34, 147–158.
1008 | ROGERS ET AL.

Gilbert, P., Clarke, M., Hempel, S., Miles, J. N. V., & Irons, C. (2004). Criticizing and reassuring oneself: An exploration of
forms, styles and reasons in female students. British Journal of Clinical Psychology, 43, 31–50. https://doi.org/10.1348/
014466504772812959
Glenn, C. R., Cha, C. B., Kleiman, E. M., & Nock, M. K. (2017). Understanding suicide risk within the Research Domain Criteria
(RDoC) framework: Insights, challenges, and future research considerations. Clinical Psychological Science, 5, 568–592.
Glenn, C. R., Kleiman, E. M., Cha, C. B., Deming, C. A., Franklin, J. C., & Nock, M. K. (2018). Understanding suicide risk within
the Research Domain Criteria (RDoC) framework: A meta‐analytic review. Depression and Anxiety, 35, 65–88. https://
doi.org/10.1002/da.22686
Glenn, C. R., & Nock, M. K. (2014). Improving the short‐term prediction of suicidal behavior. American Journal of Preventive
Medicine, 47, S176–S180.
Hames, J. L., Rogers, M. L., Silva, C., Ribeiro, J. D., Teale, N. E., & Joiner, T. E. (2017). A social exclusion manipulation interacts
with acquired capability for suicide to predict self‐aggressive behaviors. Archives of Suicide Research, 22, 32–45.
Hendin, H., Al Jurdi, R. K., Houck, P. R., Hughes, S., & Turner, J. B. (2010). Role of intense affects in predicting short‐term
risk for suicidal behavior: A prospective study. The Journal of Nervous and Mental Disease, 198, 220–225.
Hendin, H., Maltsberger, J. T., Haas, A. P., Szanto, K., & Rabinowicz, H. (2004). Desperation and other affective states in
suicidal patients. Suicide & Life‐Threatening Behavior, 34, 386–394. https://doi.org/10.1521/suli.34.4.386.53734
Husky, M., Swendsen, J., Ionita, A., Jaussent, I., Genty, C., & Courtet, P. (2017). Predictors of daily life suicidal ideation in
adults recently discharged after a serious suicide attempt: A pilot study. Psychiatry Research, 256, 79–84. https://doi.
org/10.1016/j.psychres.2017.06.035
Joiner, T. E., Hom, M. A., Hagan, C. R., & Silva, C. (2016). Suicide as a derangement of the self‐sacrificial aspect of eusociality.
Psychological Review, 123, 235–254.
Joiner, T. E., Simpson, S., Rogers, M. L., Stanley, I. H., & Galynker, I. I. (2018). Whether called Acute Suicidal Affective
Disturbance or Suicide Crisis Syndrome, a suicide‐specific diagnosis would enhance clinical care, increase patient
safety, and mitigate clinician liability. Journal of Psychiatric Practice, 24, 274–278.
Joiner, T. E., & Stanley, I. H. (2016). Can the phenomenology of a suicidal crisis be usefully understood as a suite of
antipredator defensive reactions? Psychiatry: Interpersonal and Biological Processes, 79, 107–119. https://doi.org/10.
1080/00332747.2016.1142800
Joiner, T. E., Steer, R. A., Brown, G., Beck, A. T., Pettit, J. W., & Rudd, M. D. (2003). Worst‐point suicidal plans: A dimension
of suicidality predictive of past suicide attempts and eventual death by suicide. Behaviour Research and Therapy, 41,
1469–1480.
Jollant, F., Lawrence, N. L., Olié, E., Guillaume, S., & Courtet, P. (2011). The suicidal mind and brain: A review of
neuropsychological and neuroimaging studies. The World Journal of Biological Psychiatry, 12, 319–339. https://doi.org/
10.3109/15622975.2011.556200
Jollant, F., Lawrence, N. S., Giampietro, V., Brammer, M. J., Fullana, M. A., Drapier, D., … Phillips, M. L. (2008). Orbitofrontal
cortex response to angry faces in men with histories of suicide attempts. The American Journal of Psychiatry, 165, 740–748.
Jollant, F., Near, J., Turecki, G., & Richard‐Devantoy, S. (2017). Spectroscopy markers of suicidal risk and mental pain in
depressed patients. Progress in Neuro‐Psychopharmacology and Biological Psychiatry, 73, 64–71.
Kleiman, E. M., & Nock, M. K. (2017). Real‐time assessment of suicidal thoughts and behaviors. Current Opinion in
Psychology, 22, 33–37. https://doi.org/10.1016/j.copsyc.2017.07.026
Klonsky, E. D., & May, A. M. (2015). The Three‐Step Theory (3ST): A new theory of suicide rooted in the “ideation‐to‐action”
framework. International Journal of Cognitive Therapy, 8, 114–129. doi: https://doi.org/10.1521/ijct.2015.8.2.114
Kotov, R., Krueger, R. F., Watson, D., Achenbach, T. M., Althoff, R. R., Bagby, R. M., … Zimmerman, M. (2017). The
Hierarchical Taxonomy of Psychopathology (HiTOP): A dimensional alternative to traditional nosologies. Journal of
Abnormal Psychology, 126, 454–477. https://doi.org/10.1037/abn0000258
Linehan, M. M. (1993). Cognitive‐Behavioral Treatment of Borderline Personality Disorder. New York, NY: Guilford Press.
Maj, M. (2018). Why the clinical utility of diagnostic categories in psychiatry is intrinsically limited and how we can use new
approaches to complement them. World Psychiatry, 17, 121–122. https://doi.org/10.1002/wps.20512
Malone, K. M., Szanto, K., Corbitt, E. M., & Mann, J. J. (1995). Clinical assessment versus research methods in the
assessment of suicidal behavior. The American Journal of Psychiatry, 152, 1601–1607. https://doi.org/10.1176/ajp.152.
11.1601
May, A. M., & Klonsky, E. D. (2016). “Impulsive” suicide attempts: What do we really mean. Personality Disorders, 7,
293–302.
Moll, J., de Oliveira‐Souza, R., Moll, F. T., Ignácio, A., Bramati, I. E., Caparelli‐Dáquer, E. M., & Eslinger, P. J. (2005). The moral
affiliations of disgust: A functional MRI study. Cognitive and Behavioral Neurology, 18, 68–78.
Nock, M. K., & Kessler, R. C. (2006). Prevalence of and risk factors for suicide attempts versus suicide gestures: Analysis of
the National Comorbidity Survey. Journal of Abnormal Psychology, 115, 616–623. https://doi.org/10.1037/0021‐843X.
115.3.616
ROGERS ET AL. | 1009

Nordentoft, M., Mortensen, P. B., & Pedersen, C. B. (2011). Absolute risk of suicide after first hospital contact in mental
disorder. Archives of General Psychiatry, 68, 1058–1064.
O’Connor, R. C. (2011). Towards an integrated motivational–volitional model of suicidal behaviour. In O’Connor, R. C., Platt,
S., & Gordon, J. (Eds.), International Handbook of Suicide Prevention (pp. 181–198). John Wiley & Sons, Ltd., Chichester,
West Sussex, UK.
Oquendo, M. A., & Baca‐Garcia, E. (2014). Suicidal behavior disorder as a diagnostic entity in the DSM‐5 classification
system: Advantages outweigh limitations. World Psychiatry, 13, 128–130. https://doi.org/10.1002/wps.20116
Paris, J. (2002). Chronic suicidality among patients with borderline personality disorder. Psychiatric Services, 53, 738–742.
https://doi.org/10.1176/appi.ps.53.6.738
Pigeon, W. R., Pinquart, M., & Conner, K. (2012). Meta‐analysis of sleep disturbance and suicidal thoughts and behaviors.
The Journal of Clinical Psychiatry, 73, e1160–e1167.
Popovic, D., Vieta, E., Azorin, J. M., Angst, J., Bowden, C. L., Mosolov, S., … Perugi, G. (2015). Suicide attempts in major
depressive episode: Evidence from the BRIDGE‐II‐Mix study. Bipolar Disorders, 17, 795–803. https://doi.org/10.1111/
bdi.12338
Powell, P. A., Overton, P. G., & Simpson, J. (2014). The revolting self: An interpretative phenomenological analysis of the
experience of self‐disgust in females with depressive symptoms. Journal of Clinical Psychology, 70, 562–578. https://doi.
org/10.1002/jclp.22049
Qin, P., Agerbo, E., & Mortensen, P. B. (2002). Suicide risk in relation to family history of completed suicide and psychiatric
disorders: A nested case‐control study based on longitudinal registers. Lancet, 360, 1126–1130. https://doi.org/10.
1016/S0140‐6736(02)11197‐4
Regier, D. A., Kuhl, E. A., & Kupfer, D. J. (2013). The DSM‐5: Classification and criteria changes. World Psychiatry, 12, 92–98.
https://doi.org/10.1002/wps.20050
Ribeiro, J. D., Franklin, J. C., Fox, K. R., Bentley, K. H., Kleiman, E. M., Chang, B. P., & Nock, M. K. (2016). Self‐injurious
thoughts and behaviors as risk factors for future suicide ideation, attempts, and death: A meta‐analysis of longitudinal
studies. Psychological Medicine, 46, 225–236. https://doi.org/10.1017/S0033291715001804
Ribeiro, J. D., Silva, C., & Joiner, T. E. (2014). Overarousal interacts with a sense of fearlessness about death to predict
suicide risk in a sample of clinical outpatients. Psychiatry Research, 218, 106–112. https://doi.org/10.1016/j.psychres.
2014.03.036
Ribeiro, J. D., Yen, S., Joiner, T., & Siegler, I. C. (2015). Capability for suicide interacts with states of heightened arousal to
predict death by suicide beyond the effects of depression and hopelessness. Journal of Affective Disorders, 188, 53–59.
https://doi.org/10.1016/j.jad.2015.07.037
Rimkeviciene, J., O’Gorman, J., & De Leo, D. (2015). Impulsive suicide attempts: A systematic literature review of
definitions, characteristics and risk factors. Journal of Affective Disorders, 171, 93–104. https://doi.org/10.1016/j.jad.
2014.08.044
Robins, E., & Guze, S. B. (1970). Establishment of diagnostic validity in psychiatric illness: Its application to schizophrenia.
The American Journal of Psychiatry, 126, 983–987.
Rogers, M. L., Anestis, J. C., Harrop, T. M., Schneider, M. E., Bender, T. W., Ringer, F. B., & Joiner, T. E. (2016). Examination of
MMPI‐2‐RF substantive scales as indicators of acute suicidal affective disturbance components. Journal of Personality
Assessment, 99, 424–434.
Rogers, M. L., Chiurliza, B., Hagan, C. R., Tzoneva, M., Hames, J. L., Michaels, M. S., … Joiner, T. E. (2017). Acute suicidal
affective disturbance: Factorial structure and initial validation across psychiatric outpatient and inpatient samples.
Journal of Affective Disorders, 211, 1–11. https://doi.org/10.1016/j.jad.2016.12.057
Rogers, M. L., Galynker, I., Yaseen, Z., Defazio, K., & Joiner, T. E. (2017). An overview and comparison of two proposed suicide‐
specific diagnoses: Acute suicidal affective disturbance and suicide crisis syndrome. Psychiatric Annals, 47, 416–420.
Rogers, M. L., Hom, M. A., & Joiner, T. E. (under review). Differentiating Acute Suicidal Affective Disturbance (ASAD) from
anxiety and depression symptoms: A network analysis.
Rogers, M. L., & Joiner, T. E. (2018). Lifetime acute suicidal affective disturbance symptoms account for the link between
suicide‐specific rumination and lifetime past suicide attempts. Journal of Affective Disorders, 235, 428–433.
Rogers, M. L., Tucker, R. P., Law, K. C., Bauer, B. W., Smith, C. E., Capron, D. W., … Joiner, T. E. (2018). The relationship
between negative cognitive styles and lifetime suicide attempts is indirect through lifetime acute suicidal affective
disturbance symptoms. Cognitive Therapy and Research, 1–11.
Schoenbaum, M., Kessler, R. C., Gilman, S. E., Colpe, L. J., Heeringa, S. G., Stein, M. B., … Cox, K. L. (2014). Predictors of
suicide and accident death in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS): Results
from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). JAMA Psychiatry, 71, 493–503.
https://doi.org/10.1001/jamapsychiatry.2013.4417
Shneidman, E. S. (1996). The Suicidal Mind. Oxford: Oxford University Press.
Simmons, J. M., & Quinn, K. J. (2014). The NIMH Research Domain Criteria (RDoC) Project: Implications for genetics
research. Mammalian Genome, 25, 23–31.
1010 | ROGERS ET AL.

Stanley, B., & Brown, G. K. (2012). Safety planning intervention: A brief intervention to mitigate suicide risk. Cognitive and
Behavioral Practice, 19, 256–264.
Stanley, I. H., Rufino, K. A., Rogers, M. L., Ellis, T. E., & Joiner, T. E. (2016). Acute suicidal affective disturbance: A
confirmatory factor analysis among psychiatric inpatients. Journal of Psychiatric Research, 80, 97–104.
Sublette, M. E., Milak, M. S., Galfalvy, H. C., Oquendo, M. A., Malone, K. M., & Mann, J. J. (2013). Regional brain glucose
uptake distinguishes suicide attempters from non‐attempters in major depression. Archives of Suicide Research, 17,
434–447.
Trivedi, M. H., Wisniewski, S. R., Morris, D. W., Fava, M., Kurian, B. T., Gollan, J. K., … Rush, A. J. (2011). Concise associated
symptoms tracking scale: A brief self‐report and clinician rating of symptoms associated with suicidality. The Journal of
Clinical Psychiatry, 72, 765–774. https://doi.org/10.4088/JCP.11m06840
Tucker, R. P., Michaels, M. S., Rogers, M. L., Wingate, L. R., & Joiner, T. E. (2016). Construct validity of a proposed new
diagnostic entity: Acute Suicidal Affective Disturbance (ASAD). Journal of Affective Disorders, 189, 365–378. https://doi.
org/10.1016/j.jad.2015.07.049
Vannoy, S. D., Andrews, B. K., Atkins, D. C., Dondanville, K. A., Young‐Mccaughan, S., & Peterson, A. L. (2016). Under
reporting of suicide ideation in US Army population screening: An ongoing challenge. Suicide and Life‐Threatening
Behavior, 47, 723–728.
Van Orden, K. A., Witte, T. K., Cukrowicz, K. C., Braithwaite, S. R., Selby, E. A., & Joiner, T. E. (2010). The interpersonal
theory of suicide. Psychological Review, 117, 575–600.
Waller, N. G., & Meehl, P. E. (1998). Multivariate Taxometric Procedures: Distinguishing Types From Continua. Newbury Park,
CA: Sage.
Witte, T. K., Holm‐Denoma, J. M., Zuromski, K. L., Gauthier, J. M., & Ruscio, J. (2017). Individuals at high risk for suicide are
categorically distinct from those at low risk. Psychological Assessment, 29, 382–393. https://doi.org/10.1037/
pas0000349
Wojnar, M., Ilgen, M. A., Wojnar, J., McCammon, R. J., Valenstein, M., & Brower, K. J. (2009). Sleep problems and suicidality
in the National Comorbidity Survey replication. Journal of Psychiatric Research, 43, 526–531. https://doi.org/10.1016/j.
jpsychires.2008.07.006

How to cite this article: Rogers ML, Chu C, Joiner T. The necessity, validity, and clinical utility of a new
diagnostic entity: Acute suicidal affective disturbance. J. Clin. Psychol. 2019;75:999–1010.
https://doi.org/10.1002/jclp.22743