Further Musings on Potential Predictors of Suicidal Behaivor

In the last post I discussed thoughts on why certain groupings of physiological measurements may turn out to be a better predictor of suicidal behavior than genes (check out that post here).  On top of that, I have some general ideas as to how this may play out.

I would imagine that each psychological disorder may end up having its own constellation of physiological factors with predictive power.  For instance, people with major depression without psychotic features would have a different constellation of physiological factors associated with suicidal behavior than people with schizophrenia.   The people in the major depression group may have lots of indicators of very low mood but a certain amount of anxiety / excitement too.  Currently, it is a commonly held belief among clinicians, researchers, and even the general public that a certain amount of energy is required to make a suicide attempt.  Rather than a 1 to 1 correlation between low mood and suicide - i.e. the people w/ the lowest mood are at the highest risk of making an attempt - low mood plus a certain amount of motivation/excitation to attempt is believed to be in the mix.  It's worth noting that the excitation wouldn't necessarily improve one's mood.  Low mood and excitation are not only likely to be separate and valid psychological constructs, but they would represent themselves differently physiological tests.   Speaking in terms of totally made up units of measurement to illustrate a point, a person with major depression may need lower than -100 endorphins (representing low mood) and somewhere between +15 and +30 cortisol (representing excitation) in order to qualify as being at imminent risk for suicide.  On the other hand, a person with schizophrenia may need lower than only -25 endorphins (representing low mood) and higher than +200 cortisol (representing excitation) to be at imminent risk for suicide attempt.  Continuing down the path of this totally fabricated example, high levels of excitation may be more indicative of imminent suicide risk in schizophrenia than in major depression for a couple of reasons.  If someone with schizophrenia attempts suicide, it has a decent likelihood of being because they heard a voice in their head commanding them to do so.  As such, the experience of hearing a scary voice telling them to kill themselves would hypothetically induce a physiologically state of excitation. On the other hand, a relatively low but existent amount of excitation would hypothetically be required for a person with major depressive disorder to attempt suicide.  Concurrently, their mood would presently need to be extremely low to be at risk for such destructive behavior.

Pulling back out of the examples and towards the larger picture, in short, I would imagine that each disorder would have it's own set of physiological risk factors.  Major depression, schizophrenia, bipolar, borderline personality disorder, etc. would all have different high-risk constellations.  Some more thoughts on the specifics to come.

Musings on Potential Predictors of Suicidal Behavior

I was recently asked for my thoughts about blood tests as a genetic predictor of suicide on Twitter.  I tweeted them out, but I thought I'd quickly organize them here as well.  It admittedly may be very flawed, but here's my logic:

1. Completing suicide is one isolated behavior that results from a complex myriad of genetic, biological, environmental, and situational factors.   As such, simply looking to genetics - the building blocks of life - to predict one isolated behavior seems far fetched.

2.  There's also a lot of noise introduced when your outcome is the one isolated behavior of a suicide attempt resulting in death.  Someone who may be prone to suicide, for instance, may die in an accident before they ever have the change to attempt suicide.   Further, people who may be prone to suicide otherwise may lead a charmed life & the thought may never cross their minds.  Alternatively, someone not genetically prone to suicide may have a terrible life, develop a substance abuse habit, and impulsively kill themselves one night while under the influence.  Because the environment and circumstance play such a large role in whether or not someone actually dies by suicide, looking to genetics intuitively doesn't feel right to me.  Studying epigenetic factors, however, may yield something very interesting, but my money isn't on it.  I don't think it will be the silver bullet we want it - or hype it - to be.  Think back to the human genome project. (P.S.  Psychologists will recognize this argument as part of the "low base rate behavior" issue.)

3.  It is true that suicidal behavior is linked with psychological disorders, but is perhaps more important to focus on this: the behavior of completing suicide is intimately tied to the circumstances in the immediate environment.  These immediate circumstances will have an immediate effect not a a person's genetics per se, but on their physiology.

For instance, on any given day, a woman with moderate depression may be at a certain point in her menstrual cycle, on substances, vulnerable from a myriad of factors (e.g. relationship stress, lack of sleep, health condition, etc.), and feeling particularly impulsive.  Lets just say that we add a life tragedy to this vulnerable mix of factors and she gets admitted to an inpatient unit for suicidal thoughts.  Eventually she reports her suicidal thoughts have remitted, she is discharged, and then our hypothetical woman unfortunately makes a suicide attempt.  Some of the aforementioned factors (e.g. menstrual cycle, etc.) have a specific physiological impact.  If we had measurements taken from the inpatient unit of this woman's estrogen/progesterone levels, oxytocin, waking levels of cortisol, toxicity, etc. it would result in a specific constellation of physiological factors.  Over time, scientists can examine which constellation(s) of physiological indicators most often co-occur with recent (serious) suicide attempts / completions.  Determining & using immediate constellations of physiological factors to predict suicidal behavior in the near future seems to me like it will be much more accurate (i.e. have "incremental predictive validity") than our current tools (e.g. self-report questionnaires).  The general idea is that in the future we may be able to divine what people are actually feeling based on physiological measures rather than self-report.

4.  One last thought about the utility (and sensitivity) of genetic testing for suicide:
Not only do I think that blood tests for genetic factors will not yield reliable predictors of suicide completion, they will likely not be of much practical utility.  Consider this: what course of action must a clinician take with the information that a person is at genetic risk for suicide?  If someone is admitted to a psychiatric inpatient unit because of depression and suicidal thoughts, at some point they report they are not imminently at risk.  At that point, we must then discharge them from the hospital.  We would not be able to detain them longer based on a genetic test.  Correct?  How much longer would we keep someone on an inpatient unit based on a genetic test?  Genetic markers are not what we call sensitive measures - they are not sensitive to change.  They are static.  We would, however, have a more firm basis for detaining someone in the hospital if we had evidence that certain physiological constellations were present in a person & evidence that this type of constellation is associated with imminent risk of suicide.  Over time, we would have an idea about how generally someone would be feeling based on the output of physiological tests. Of course, how accurate or difficult to manipulate these hypothetical physiological constellations may be is unknown.  But if I were a betting woman, I would put my money on the scientists examining circumstantial physiological compositions winning the race of determining the most accurate, useful, & sensitive predictor of suicidal behavior.

In short, a suicide attempt is a behavior, not a disorder.  I'm not so sure that treating suicide attempts like a disorder by examining genetic contributions will produce the best predictors of this behavior.  Exploring physiological factors that represent immediate shifts in a person's internal experience however, intuitively feels more promising to me.

P.S.  This post was in response to this CNN article: link.

BITE for Eating Disorders

Hi there,

This is more of an announcement than an actual post!  Here's the big news: Dr. Dina Hirsch & I are cooking up a new eating disorder treatment manual I think you might like. For updates, follow us at @BITEforEDs.

Details about the BITE manual & website are to come!

Best,
The BITE Therapy Team

Letters to a Young Student of Psychology

Letters to a Young Student of Psychology

Background:

I was recently asked by a young student in psychology to answer questions for a report she was writing.  The report was on working with patients who are experiencing problems that hit close to home.  Below are both her questions and my answers. Because I graduated from my last clinical training year today, I thought it would be a nice day to publish this post.

Response:

Dear Young Psychology Student,

In the text below, I've done my best to fully answer your questions about my experience training as a psychologist.

Question 1:

Have you worked with school-aged children and adolescents? Briefly explain in what capacity you have worked with this population. What were the successes? What were the challenges?

Answer 1:

Yes, I am at the very end of my 6th year in a clinical psychology PhD program and I just completed internship at North Shore LIJ Hospital (I came directly from my graduation ceremony to this blog, in fact).  On internship I carried a caseload of child & adolescent patients; however, my prior training was largely with adults.  

For the first six months at North Shore LIJ, I carried a caseload on the locked adolescent inpatient unit at the hospital.  There I treated patients with first-break psychosis, recent suicide attempts, or physically violent behaviors.  During the second six months of my position, I worked with patients medically at risk secondary to severe eating disorders.  My patients were either hospitalized on a medical inpatient unit or attending the eating disorders day program, which is a 8:30am to 5:30pm fully structured hospital program.  Additionally, for this entire year, I carried an outpatient caseload.

I conduct only evidence based treatments (EBTs; e.g. cognitive behavioral therapy). So, in terms of successes: when Evidence Based Treatment is being conducted, a lot of symptoms tend to improve.  Therefore, I get to see a lot of success.  Specifically, I love seeing patients recover from anorexia nervosa.  It is consistently amazing to literally see a great deal of progress made over a short period of time.  For instance, we typically treat people who start off at risk of dying from being so underweight until they gain upwards of 15-20 pounds.  You can see that progress. At LIJ, we have a very strict refeeding program that promotes both physical and mental health.  

The biggest challenges for me are:

A) Working with parents who do not accept diagnoses.  Many times parents of children with certain disorders (e.g. autism or eating disorders) refuse to accept the diagnosis. This can be particularly frustrating when this prevents the child from receiving services during a critical phase of their development or illness.  If the parent doesn't come to accept a diagnosis in time, that child runs the risk of being severely affected for his / her entire life by the parent's lack of acceptance.

B) Calling child protective services (CPS) under some conditions.  In some extreme circumstances, CPS must be legally called when parents are neither abusing nor neglecting their children.  Parents may simply not be equipped to deal with their child’s emotional needs.  For instance, if your patient premeditatively stabs a sibling and threatens to do it again, a CPS call may be made even if the parents are "good" parents.  In a case like this, the issue is that parents are unable to control risk of one of their children seriously injuring / killing another of their children.  If the parent does not take the appropriate measures to ensure the safety of the victimized child by making (sometimes expensive) accommodations for the violent child, CPS may be called.  It's very difficult to be in situations like these.  Although in my experience only very reasonable accommodations are requested, in order for parents to follow through, they must emotionally accept that one of their children is a serious threat.  A well-intentioned parent may have the "he won't intentionally stab his sister again... it will be ok" type of mindset.  Of course, this is unacceptable when a patient has clearly expressed murderous intent.

Question 2:  Have you worked with a child that has lost a parent?  What have you found challenging? What have you found to be helpful for the client?

Answer 2:

I haven't worked with a child grieving the death of a parent; however, I have worked with patients grieving the loss of a parent. Specifically, patients in foster care grieve the loss of their parent in a primary care giving roll.  Some parents clearly demonstrated neglectful / abusive behavior, while some parents were not able to protect others from the violent behavior of the patient.

Challenging: It pulls at my heart strings when patients grieving the loss of a parent ask questions about the future.  The question when the child is removed from the home is always “what is going to happen to me?” and I can’t really answer those questions.  While some foster homes and residential settings are wonderful, others are not.  When working with patients in the hospital, I have no idea about the quality of the home where they would be next.  That can be tough.

Helpful: It is helpful not to intervene when a patient is actively grieving.  While on internship, I have had to break very difficult news to patients and have been present at the time the very instant the grieving process started.  In that specific moment, my job isn’t to relate to the patients or actively try and make them feel better.  My job is just sit there with the person and be as fully present to them as possible.  In instances like this, only when the person truly wants to be alone, do you leave them alone.  

In terms of advice, I would say this: knowing when grieving ends and a disorder begins is imperative.  Unfortunately, there are no easy rules to follow about this.  You can't say something like "oh, after two months, this child should be over the death of their parent."  You can, however, assess whether or not the person is emotionally avoidant.  Grieving implies that the person is actually experiencing the emotion of sadness that naturally accompanies loss.  If the person is doing things like drugs etc to avoid feelings of grief, we have a problem.  Once you figure out if/how the patient is avoiding, then rule is this: if the person is actually experiencing grief, sit with the emotion; however, if there is dysfunction secondary to avoidance, then intervene.  I think the ability to skillfully assess and intervene will naturally come with experience.  There's a whole book to write about this.

Question 3:

Is there a population that you see yourself in or relate to on an emotional level? What is that like? What has helped you maintain emotional distance? What has helped you to not “take the work home?”

Answer 3:

I have thought about this a lot, but I’ve never actually talked to anyone about it.  So here we go.  I think that if you really undergo a lot of self-examination over many years across many different experiences, you have the ability to remember even very mild emotional reactions, inclinations, and urges.  If you’re aware of the wide breadth of your own experience, it can be very easy to relate to patients, at least on some level.  In short, understanding yourself helps you understand others.  Because of this, I have found that I relate to every patient about something on an emotional level (to varying degrees of course).  

There have been a few times where I really see myself in a patient.  When this happens, it forces me to look at decisions I have made.  In these circumstances, I internally relate as much as I can to the patient and use genuine sympathy and understanding to build the relationship.  And with a strong relationship, we can facilitate adaptive change together.

I didn’t think it is necessary - or even helpful - to maintain emotional distance.  I don't wall myself off from experiencing my own emotions because that usually ends poorly.  It is helpful to use my emotions in session.  That isn't to say though, that a therapist shouldn't maintain an objective lens.  A good CBT therapist will know how and when to think rationally.  In fact, it is wholly possible to think rationally about a scenario while also experiencing real emotion.

In a way, you should take your work home.  Of course it isn't helpful to be overly involved with your patient's lives, but if a patient's experience was emotionally triggering for you, take home your own emotion about your own life.  Process that.

Question 4:  

Do you have any advice for me?

Answer 4:

I know that the reason why you're asking these questions, Young Student in Psychology, is that you lost a parent and you're worried that having a patient with a similar experience will be too much.  So listen, if you’re working with a patient who lost a parent and it triggers sadness about your own loss, sit with that.  Accept it.  Pay attention to it.  Ignoring this opportunity for your own emotional growth would only be hurting you.  You are going to have strong emotions and that is ok.  In this field, we have the privilege of helping other people through difficult emotions, which also happen to provide us with special opportunities for insight into ourselves.

In terms of advice, I would say this: be genuine and don’t avoid.  If something upsets you, obviously don’t make the session about your problems, but allow yourself to feel emotions about the patient’s pain in session and express your own pain when you get home.  Over time, exposing yourself to what you’re afraid of or emotionally sensitive to will make you stronger than you can anticipate.  Although the hole in your life caused by the death of a parent will never close, it will become easier to manage your emotions about this.  The more opportunities you give yourself to experience those emotions, the better therapist you will become and the stronger you will be.  Make mistakes and put yourself in situations you are not sure you can handle.

Life Isn't a Story: The Narrative Fallacy

I noticed something familiar at the very top of an important list.  Author and designer, Frank Chimero, published a post on New Years Day entitled Some Lessons I Learned in 2013.  The number one lesson here is "life isn't a story."  But seeing as this blog isn't life, here's a true story.

The True Story:
One late December evening in 2013, I was shuttling Frank around Brooklyn in my brand new but beat up car.  The winter was pretty rough in NYC and my car was literally weathered.  Unfortunately, it wasn't only a trying winter, but a trying year.  As such, we were discussing how not to handle hardship.  Frank said something along the lines of "I know that creating a story out of life messes people up.  But I don't know why.  Tara, you're a psychologist and you've probably thought much more about this.  Why is it that making life into a narrative isn't helpful?"  Frank was in for an earful, a blog post, and a birthday present.

I immediately conjured up a label for the phenomenon Frank was describing, "the narrative bias."  My next thought was "hm, maybe I'm the first person to think up this term... wouldn't that be cool?"  Five months later, I finally got around to looking into it.  So today, which is Frank's birthday, I did a Google search for "narrative bias."  Then it happened: I learned that someone I've actually met beat me to the punch!  He's not even a psychologist.  His name is Nassim Taleb.  He wrote a book called The Black Swan.  And no, not the one about the ballet dancer, but the one about improbable events (how relevant).  Anyhow, I was introduced to Taleb while dining at Naya, a swanky Lebanese restaurant in midtown, with a friend of mine who is a professor of aerospace engineering (or as we laypeople call it, "rocket science").  But the events of that night are a whole other story!

The Narrative Fallacy:
Much to my dismay, Taleb more astutely coined this concept as "the narrative fallacy."

The narrative fallacy addresses our limited ability to look at sequences of facts without weaving an explanation into them, or, equivalently, forcing a logical link, an arrow of relationship upon them. Explanations bind facts together. They make them all the more easily remembered; they help them make more sense. Where this propensity can go wrong is when it increases our impression of understanding.

—Nassim Nicholas Taleb, The Black Swan

The Story I Told You:
Clearly, humans are verbal animals who are naturally inclined to connect series of events into a narrative.  I've already done it here.  First, I introduced you to Frank.  In case you missed it, I very intentionally called him an "author," not a "writer."  Anyone can be a writer, not everyone can be an author.  Next, I included a link to Frank's Twitter page so that you might happen across the fact that he has quite a following.  All of a sudden, this story is a bit more interesting.  You were already being sold a story before it was told.  Next, I'm officially telling you a story about how Frank and I are palling around BK.  For some artistic flare, I made an uncharacteristic attempt at a harsh-winter-and-personal-hardship metaphor.  We were talking about serious stuff.  But wouldn't ya know it, today is Frank's birthday!  There's levity promised.  But wait, what's his birthday present?  Perhaps you, the reader, will have a voyeuristic opportunity to peek in on a slice of this friendship.  Then, depending on your opinion, another entertaining stunt or cheap trick was pulled.  I told you how a real-life rocket scientist introduced me to Nassim Taleb, the guy who created a better term than the one I was trying to coin with this blog post [It's a letdown.  Maybe you wanted me to be the first because you're reading a story about it.]  Name drop, plop.  But hey... were you interested?  Did it work?  Maybe, maybe not.

The Story I Told Myself:
It doesn't matter if it worked.  Because now you see, the problem is this: in the process of attempting to entertain you with a story, I was telling myself a story.  Reflecting on the company I keep, I'm now starting to liken my life to Midnight in Paris even though it's 8pm in Brooklyn.  Nevertheless, I'm sitting here in the same neighborhood that my friend's mom said "it wasn't worth the risk" to come visit me in, and I'm really starting to consider myself a New York City intellectual.  Spilling coffee on my socks this morning seems like a distant memory.  The fact that I befriended the professor while working a 12 hour shift at a cigar bar cleaning ashtrays is totally lost.  Instead, I start to bet that the reader thinks the professor and I became friends at something like a highly secretive Freemason meeting... that allows women.  Perfect.  The professor and I are practically Freemasons anyhow, right?

Wrap-up:
In short, writing a two paragraph story has made me a delusional egomaniac.  It appears that stringing completely factual events together into a story has a side effect: myopic viewpoint.  A story - whether it be funny or sad -is interesting.  A story is easy to remember.  But when we remember a story, we lose the real richness of our actual experience.  Our balance is lost.  The altered photograph becomes the memory.

Frank, I hope that my attempt at storytelling and delusions have helped illustrate why creating a narrative out of life messes people up.  Anyhow, I need to jet.  Phone call with the Pope!
P.S. Happy birthday.

-Tara