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Suicidal Risk and Management in Borderline Personality Disorder

  • PERSONALITY DISORDERS (H KOENIGSBERG, SECTION EDITOR)
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Abstract

This paper reviews recent advances in our understanding of suicidality in borderline personality disorder (BPD), with a focus on suicide risk assessment, guidelines for treatment, and medicolegal concerns. Relevant material on distinctions between suicide completers and suicide attempters, contributions of published American Psychiatric Association Guidelines, the controversial role of hospitalization, and management strategies regarding litigation is addressed. Despite accumulating data on suicidality in BPD, the current state of knowledge offers only partial clues to help identify the BPD patients most at risk of death by suicide, and offers a limited armamentarium of treatment targeted to suicide prevention, creating discomfort in clinicians and fears regarding litigation in the event of a successful suicide. Promising new interventions include less resource-intensive psychotherapies as well as brief crisis intervention.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. American Psychiatric Association: Practice Guideline for the Treatment of Patients with Borderline Personality Disorder. Am J Psychiatry, 2001. 158(Oct suppl).

  2. Paris J. Chronic suicidality among patients with borderline personality disorder. Psychiatr Serv. 2002;53:738–42.

    Article  PubMed  Google Scholar 

  3. Gunderson JG, Ridolfi ME. Borderline personality disorder. Suicidality and self-mutilation. Ann N Y Acad Sci. 2001;932:61–73.

    Article  PubMed  CAS  Google Scholar 

  4. Soloff PH, Fabio A, Kelly TM, et al. High-lethality status in patients with borderline personality disorder. J Pers Disord. 2005;19:386–99.

    Article  PubMed  Google Scholar 

  5. American Psychiatric Association: Practice Guideline for the Assessment and Treatment of Patients with Suicidal Behaviors. Am J Psychiatry 2003, 160(Nov suppl. The complete guideline, including Parts A and B, was published in May 2004 as a compendium and is available at: http://www.psych.org/psych_pract/treatg/pg/pg_suicidalbehaviors).

  6. ••McGirr A, Paris J, Lesage A, et al.: An examination of DSM-IV borderline personality disorder symptoms and risk for death by suicide: a psychological autopsy study. Can J Psychiatry 2009, 54:87–92. This important paper examines the role of BPD criteria in suicide completion using psychological autopsy.

    PubMed  Google Scholar 

  7. McGirr A, Paris J, Lesage A, et al. Risk factors for suicide completion in borderline personality disorder: a case-control study of cluster B comorbidity and impulsive aggression. J Clin Psychiatry. 2007;68:721–9.

    Article  PubMed  Google Scholar 

  8. Korzekwa MI, Dell PF, Links PS, et al. Estimating the prevalence of borderline personality disorder in psychiatric outpatients using a two-phase procedure. Compr Psychiatry. 2008;49:380–6.

    Article  PubMed  Google Scholar 

  9. Stone M. Fate of borderline personality disorder patients. New York: Guilford; 1990.

    Google Scholar 

  10. Isometsa ET, Lonnqvist JK. Suicide attempts preceding completed suicide. Br J Psychiatry. 1998;173:531–5.

    Article  PubMed  CAS  Google Scholar 

  11. Paris J. Half in love with easeful death: the meaning of chronic suicidality in borderline personality disorder. Harv Rev Psychiatry. 2004;12:42–8.

    PubMed  Google Scholar 

  12. Pompili M, Girardi P, Ruberto A, Tatarelli R. Suicide in borderline personality disorder: a meta-analysis. Nord J Psychiatry. 2005;59:319–24.

    Article  PubMed  Google Scholar 

  13. Lesage AD, Boyer R, Grunberg F, et al. Suicide and mental disorders: a case-control study of young men. Am J Psychiatry. 1994;151:1063–8.

    PubMed  CAS  Google Scholar 

  14. Berk MS, Jeglic E, Brown GK, et al. Characteristics of recent suicide attempters with and without Borderline Personality Disorder. Arch Suicide Res. 2007;11:91–104.

    Article  PubMed  Google Scholar 

  15. Brodsky BS, Groves SA, Oquendo MA, et al. Interpersonal precipitants and suicide attempts in borderline personality disorder. Suicide Life Threat Behav. 2006;36:313–22.

    Article  PubMed  Google Scholar 

  16. Horesh N, Sever J, Apter A. A comparison of life events between suicidal adolescents with major depression and borderline personality disorder. Compr Psychiatry. 2003;44:277–83.

    Article  PubMed  Google Scholar 

  17. Soloff PH, Lynch KG, Kelly TM. Childhood abuse as a risk factor for suicidal behavior in borderline personality disorder. J Pers Disord. 2002;16:201–14.

    Article  PubMed  Google Scholar 

  18. •Chesin MS, Jeglic EL, Stanley B: Pathways to high-lethality suicide attempts in individuals with borderline personality disorder. Arch Suicide Res 2010, 14:342–62. This rigorous paper examines path analysis to high-lethality suicide in BPD.

    Article  PubMed  Google Scholar 

  19. Clark DC, Gibbons RD, Fawcett J, Scheftner WA. What is the mechanism by which suicide attempts predispose to later suicide attempts? A mathematical model. J Abnorm Psychol. 1989;98:42–9.

    Article  PubMed  CAS  Google Scholar 

  20. Joiner Jr TE. The trajectory of suicidal behavior over time. Suicide Life Threat Behav. 2002;32:33–41.

    Article  PubMed  Google Scholar 

  21. ••Soloff PH, Fabio A: Prospective predictors of suicide attempts in borderline personality disorder at one, two, and two-to-five year follow-up. J Pers Disord 2008, 22:123–34. This was a prospective study examining suicide attempts in BPD.

    Article  PubMed  Google Scholar 

  22. Garcia-Forero C, Gallardo-Pujol D, Maydeu-Olivares A, Andres Pueyo A. Disentangling impulsiveness, aggressiveness and impulsive aggression: an empirical approach using self-report measures. Psychiatry Res. 2009;168:40–9.

    Article  PubMed  Google Scholar 

  23. CG78 Borderline personality disorder (BPD): NICE guideline. 28 January 2009. Available at http://guidance.nice.org.uk/CG78. Accessed September 2011.

  24. Oldham JM: Guideline Watch: Practice Guideline for the Treatment of Patients With Borderline Personality Disorder. 2005, American Psychiatric Association: Arlington, VA. Available at http://www.psych.org/psych_pract/treatg/pg/prac_guide.cfm. Accessed September 2011.

  25. Paris J. Is hospitalization useful for suicidal patients with borderline personality disorder? J Pers Disord. 2004;18:240–7.

    Article  PubMed  Google Scholar 

  26. Oldham JM. Borderline personality disorder and suicidality. Am J Psychiatry. 2006;163:20–6.

    Article  PubMed  Google Scholar 

  27. Linehan MM, Comtois KA, Murray AM, et al. Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Arch Gen Psychiatry. 2006;63:757–66.

    Article  PubMed  Google Scholar 

  28. Bateman A, Fonagy P. Effectiveness of partial hospitalization in the treatment of borderline personality disorder: a randomized controlled trial. Am J Psychiatry. 1999;156:1563–9.

    PubMed  CAS  Google Scholar 

  29. Kernberg OF, Yeomans FE, Clarkin JF, Levy KN. Transference focused psychotherapy: overview and update. Int J Psychoanal. 2008;89:601–20.

    Article  PubMed  Google Scholar 

  30. Mehlum L. Clinical challenges in the assessment and management of suicidal behaviour in patients with borderline personality disorder. Epidemiol Psichiatr Soc. 2009;18:184–90.

    PubMed  Google Scholar 

  31. Blum N, St John D, Pfohl B, et al. Systems Training for Emotional Predictability and Problem Solving (STEPPS) for outpatients with borderline personality disorder: a randomized controlled trial and 1-year follow-up. Am J Psychiatry. 2008;165:468–78.

    Article  PubMed  Google Scholar 

  32. Stanley B, Brodsky B, Nelson JD, Dulit R. Brief dialectical behavior therapy (DBT-B) for suicidal behavior and non-suicidal self injury. Arch Suicide Res. 2007;11:337–41.

    Article  PubMed  Google Scholar 

  33. Zanarini MC, Frankenburg FR. A preliminary, randomized trial of psychoeducation for women with borderline personality disorder. J Pers Disord. 2008;22:284–90.

    Article  PubMed  Google Scholar 

  34. Leichsenring F, et al. Borderline personality disorder. Lancet. 2011;377:74–84.

    Article  PubMed  Google Scholar 

  35. Stanley B, Siever LJ. The interpersonal dimension of borderline personality disorder: toward a neuropeptide model. Am J Psychiatry. 2010;167:24–39.

    Article  PubMed  Google Scholar 

  36. Hopko DR, Sanchez L, Hopko SD, et al. Behavioral activation and the prevention of suicidal behaviors in patients with borderline personality disorder. J Pers Disord. 2003;17:460–78.

    Article  PubMed  Google Scholar 

  37. Sansone RA. Chronic suicidality and borderline personality. J Pers Disord. 2004;18:215–25.

    Article  PubMed  Google Scholar 

  38. •Zaheer J, Links PS, Liu E: Assessment and emergency management of suicidality in personality disorders. Psychiatr Clin North Am 2008, 31:527–43, viii–ix. This paper reviews the epidemiology of suicide and BPD and provides an approach to the suicidal patient presenting in the emergency department.

  39. Black DW, Blum N, Pfohl B, Hale N. Suicidal behavior in borderline personality disorder: prevalence, risk factors, prediction, and prevention. J Pers Disord. 2004;18:226–39.

    Article  PubMed  Google Scholar 

  40. Vijay NR, Links PS. New frontiers in the role of hospitalization for patients with personality disorders. Curr Psychiatry Rep. 2007;9:63–7.

    Article  PubMed  Google Scholar 

  41. Linehan MM. Cognitive behavioral therapy of borderline personality disorder. New York: Guilford; 1993.

    Google Scholar 

  42. Dawson D, MacMillan HL. Relationship management of the borderline patient: from understanding to treatment. New York: Brunner/Mazel; 1993.

    Google Scholar 

  43. Chiesa M, Fonagy P, Holmes J, Drahorad C. Residential versus community treatment of personality disorders: a comparative study of three treatment programs. Am J Psychiatry. 2004;161:1463–70.

    Article  PubMed  Google Scholar 

  44. Berrino A, Ohlendorf P, Duriaux S, et al. Crisis intervention at the general hospital: an appropriate treatment choice for acutely suicidal borderline patients. Psychiatry Res. 2011;186:287–92.

    Article  PubMed  Google Scholar 

  45. Chemtob CM, Hamada RS, Bauer G, et al. Patients’ suicides: frequency and impact on psychiatrists. Am J Psychiatry. 1988;145:224–8.

    PubMed  CAS  Google Scholar 

  46. Hendin H, Haas AP, Maltsberger JT, et al. Factors contributing to therapists’ distress after the suicide of a patient. Am J Psychiatry. 2004;161:1442–6.

    Article  PubMed  Google Scholar 

  47. Krawitz R, Batcheler M. Borderline personality disorder: a pilot survey about clinician views on defensive practice. Australas Psychiatry. 2006;14:320–2.

    PubMed  Google Scholar 

  48. Blinder M. Suicide, psychiatric malpractice, and the bell curve. J Am Acad Psychiatry Law. 2004;32:319–23.

    PubMed  Google Scholar 

  49. Gutheil TG. Suicide, suicide litigation, and borderline personality disorder. J Pers Disord. 2004;18:248–56.

    Article  PubMed  Google Scholar 

  50. Krawitz R, Jackson W, Allen R, et al. Professionally indicated short-term risk-taking in the treatment of borderline personality disorder. Australas Psychiatry. 2004;12:11–7.

    Article  PubMed  Google Scholar 

  51. Maltsberger JT. Calculated risk taking in the treatment of suicidal patients: ethical and legal concerns. Death Stud. 1994;18:439–52.

    Article  PubMed  CAS  Google Scholar 

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Disclosure

Dr. Goodman has received grant support the US Department of Defense and Veterans Administration and received honoraria from the Northern California Psychiatric Association.

Dr. Paris has received royalties from Guilford Press.

Ms. Roiff and Ms. Oakes reported no potential conflicts of interest relevant to this article.

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Correspondence to Marianne Goodman.

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Goodman, M., Roiff, T., Oakes, A.H. et al. Suicidal Risk and Management in Borderline Personality Disorder. Curr Psychiatry Rep 14, 79–85 (2012). https://doi.org/10.1007/s11920-011-0249-4

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