"Anita" was a 24-year-old single female referred to our crisis intervention team by her family doctor for a suicide risk assessment. Prior to being seen, the emergency department staff noted that she had been previously diagnosed with borderline personality disorder (BPD). Upon being assessed, Anita stated, "My doctor doesn't know what to do with me, and I think he's fed up with me," and said that she only came to our crisis service because she promised her doctor she would. She felt that there was no hope that things could be better and did not believe there was a future for her.
Two days prior to the assessment, Anita discharged herself from our inpatient service after a brief admission following an episode of self-injury. She acknowledged that her self-injury had become more frequent and severe over the past six months and suicide attempts had increased to once a month. Anita also reported increased abuse of alcohol and marijuana. In addition, she felt like a failure with respect to her suicide attempts, as she stated, "See, I'm such a loser, I can't even kill myself right."
Anita had made several previous suicide attempts, which she believed were different from her self-injury, which she described as "easing the tension" and helping her "feel calmer." She stated, "The more overwhelmed I feel, the deeper I need to cut to calm myself." Suicide attempts occurred after a series of severe self-injuries that required medical attention. She had been hurting herself since age 5 and suffered from "crazy-making, rollercoaster" moods that fluctuated dramatically within hours. Her most common suicide attempt method was by overdosing on her medications. She had had several admissions, three in which she was admitted to an intensive care unit (ICU) because of an overdose-induced coma and most other admissions lasting three to five days. Sometimes a hospital admission was helpful for Anita because it gave her a sense of safety and containment. She felt infuriated when she was automatically discharged if she self-injured while being an inpatient. She attempted suicide twice on an inpatient unit, using bed sheets to try to hang herself. Anita has not asked for help when she has been in distress or feeling suicidal, and she stated, "I'm bad and deserve to die." Anita gave a history of using alcohol and marijuana to sleep, stating, "It helps me get away from everything." She reported drinking excessively when she was really stressed and had been drinking heavily for a few weeks prior to this assessment.
Anita was employed full-time. She temporarily reduced her hours to part-time because she felt overwhelmed and stated, "I can't handle it." She expected her boss would fire her in the near future, identifying that her work was not up to standard and she was taking more time off work due to her inability to concentrate on her job.
She was estranged from her family and had few supports outside of her work colleagues. Anita's father was physically and sexually abusive. She believed her mother never cared about her, as she reported, "My mother knew about the abuse but never did anything." Anita was recently raped but did not report it because a friend told her it was her fault. She blamed herself, stating, "I'm the one who's stupid for letting it happen." She reported having no close friends as "no one understands" her. She has a younger sister with whom she has intermittent contact. She was concerned for her sister because she was also beginning to self-injure, and Anita felt like a "bad sister" because she believed her sister must have learned this behavior from her. Her contact with her sister was intermittent because of her sister's continued relationship with their mother, with whom Anita did not want any contact.
Bender DS, Dolan RT, Skodol AE et al. (2001), Treatment utilization by patients with personality disorders. Am J Psychiatry 158(2):295-302.
Boggild AK, Heisel MJ, Links PS (2004), Social, demographic, and clinical factors related to disruptive behaviour in hospital. Can J Psychiatry 49(2):114-118.
Gunderson JG (1984), Borderline Personality Disorder. Washington, D.C.: American Psychiatric Press.
Koerner K, Linehan MM (2000), Research on dialectical behavior therapy for patients with borderline personality disorder. Psychiatr Clin North Am 23(1):151-167.
Linehan M (1993), Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York: Guilford Press.
Links PS, Gould B, Ratnayake R (2003), Assessing suicidal youth with antisocial, borderline, or narcissistic personality disorder. Can J Psychiatry 48(5):301-310 [see comment].
Stanley B, Gameroff MJ, Michalsen V, Mann JJ (2001), Are suicide attempters who self-mutilate a unique population? Am J Psychiatry 158(3):427-432.
Yen S, Shea MT, Pagano M et al. (2003), Axis I and axis II disorders as predictors of prospective suicide attempts: findings from the collaborative longitudinal personality disorders study. J Abnorm Psychol 112(3):375-381 [see comment].
Zanarini MC, Frankenburg FR, Hennen J, Silk KR (2004), Mental health service utilization by borderline personality disorder patients and Axis II comparison subjects followed prospectively for 6 years. J Clin Psychiatry 65(1):28-36.