Table 1 Descriptions of the four subtypes of suicidality. (Table 2 in de Winter et al. 2023 [3])

Perceptual Disintegration (psychotic disturbed perception/behaviour) (PD)

Suicidality originates from psychosis, which can often be accompanied by affective (depressive) dysregulation or can be affected by it. Usually, the psychotic state has only been present for probably a short time (rather days or weeks than months) and is noticed (or becomes apparent) because of its severity. Suicidality may originate from depressogenic cognition; however, in that case, the severity has developed to such a level that it can be seen as a mood-congruent or mood-incongruent psychotic state. The distress can be understood, but the severity cannot be perceived as comprehensible anymore by the examiner. A classic state is a depression with mood-congruent psychotic features. However, it can also appear among people who, while in a psychotic state, are ordered by their delusions to hurt themselves

Primary Depressive Cognition (PDC)

Suicidality stems primarily from a depressive thought process and there are no psychotic features (yet). The depressive state can be present for a while (eg, weeks or months). Thoughts of suicide, which are part of the cognition and present on a daily basis, are characteristic. There is clear evidence of distress, which can be noticed by the examiner because of the depressive thought process. A classic example would be a depressive disorder, but primary depressive cognition may also be part of an anxiety disorder, autism, etc. The features of a personality disorder may be mixed with the depressive state, or the depressive state may be caused by a personality disorder and become part of a returning thought pattern in which negative cognitions and Beck cognitive triad can be present (negative views about oneself, negative views about the world, and negative views about the future)

Psychosocial Turmoil (PT)

Suicidality stems primarily from a severe loss or blow to the ego, leading to a complete upheaval of someone’s life. The person experiences enormous guilt, severe shame, or does not dare to look another in the eye anymore or experiences a downfall without being in a psychotic state. There is an unbearable anguish, which leads to a need for release from that pain or the need not to exist anymore, to not be able to feel or escape the awful misery or pending dread. Usually, someone has been in this state for a short time (hours, days, or weeks). Drug use can be extra provoking. The stress is perceivable for the examiner from the perspective of loss or a blow to the ego and there may be slight psychotic features, but one can follow the narrative. Underlying dysregulation of the impulsivity can worsen the state and increase the risk of a lethal outcome

Inadequate Coping/communication (IC)

Suicidality stems from a severe feeling of distress and not being able to communicate this properly. There is difficulty with formulating an adequate request for help and one seems to be hoping for a solution by demonstrating suicidality. This behaviour usually exists for a longer period (months) and fluctuates severely. This type of a more chronic suicidality is often seen as part of a personality disorder such as a borderline personality disorder. Also, drug use can be an important provoking factor. Suicidality is perceived by others as “externalizing” and fake and can result in aid workers feeling “trapped” in the dynamics. The behaviour can coincide with experiences of loss with which the powerlessness is externalized and not internalized. Often, the support system is exhausted and professionals are viewed as failing. The major risk is for professionals to feel manipulated, and for the person who is assessed to feel misunderstood and not taken seriously, which leads to an amplification of the behaviour, accompanied by an increased risk of suicide. Contrary to how it is perceived by others, the person is genuinely in distress. Suicide can be used as the ultimate way to communicate about the distress caused by the perceived unfair or rejection judgment of the person (especially recognizing and exploring the countertransference and offering help to the underlying motivators of suicidality are essential with this type)