The clinical assessment of the patient with BPD in crisis is complicated. Often, these patients have made multiple suicide attempts, and it is unclear whether a short-term admission will have any impact on the ongoing risk of suicidal behavior. The Figure demonstrates a way of assessing and communicating the suicide risk of patients with BPD and a history of repeated suicide attempts (Links et al., 2003). (Due to copyright concerns, this Figure cannot be reproduced online. Please see p62 of the print edition--Ed.)
These patients are typically at a chronically elevated risk of suicide, much above that of the general population. This risk exists based on the patient's history of multiple attempts.
In addition to the history of multiple attempts, the history of self-injurious behavior also increases the risk for suicide (Linehan, 1993; Stanley et al., 2001). Stanley and colleagues (2001) found that patients with self-injurious behavior were at risk for suicide attempts because of their high levels of depression, hopelessness and impulsivity. They also tend to misperceive and underestimate the lethality of their suicidal behaviors. The patient's level of chronic risk can be estimated by taking a careful history of the previous suicidal behavior and focusing on the times when the patient may have demonstrated attempts with the greatest intent and medical lethality. The physician can then estimate the severity of the patient's ongoing chronic risk for suicide. In Anita's case, she was assessed at a moderate-to-high chronic risk for suicide, based on her history of not calling for help when suicidal and previous high-lethal attempts that required ICU admissions.
In patients with BPD, the acute-on-chronic level of risk is related to several factors (Figure, shaded arrow) (Links et al., 2003). (Due to copyright concerns, this Figure cannot be reproduced online. Please see p62 of the print edition--Ed.) An acute-on-chronic risk will be present if the patient is suffering from comorbid major depression or if the patient is demonstrating high levels of hopelessness or depressive symptoms, as is the case with Anita.
A study by Yen et al. (2003) supported the need to look for an acute-on-chronic change in status. In the clinical scenario presented, a worsening of depression or substance use occurred in the month preceding a suicide attempt, relative to the general levels of change in all other months. Patients with BPD are known to be at risk for suicide around times of hospitalization and discharge. Anita presenting in crisis two days after discharge from an inpatient setting illustrates a time when the risk assessment must be very carefully completed to ensure that a proper disposition is made. This patient is potentially at an acute-on-chronic risk, and the assessment cannot be truncated because of the recent discharge from hospital. Proximal substance abuse can increase suicide risk. The diagnosis of substance abuse increases the chronic risk for suicidal behavior. For Anita, the accumulation of recent stressful life events such as the rape, her concern about her sister's safety, and/or the lack of intimate or family support also indicate periods of high risk. The risk is acutely elevated in patients who have less family support, or if they have lost or perceive the loss of an important relationship. This is demonstrated in Anita's case, as she has few supports and perceives that her long-time family physician is ready to reject her. In addition, she believes that her job is at risk.
Gunderson (1984) made the point that the patient with BPD who is attempting to manipulate the environment is at a lesser risk than the patient with BPD who presents in a highly regressed, dissociative state. At these times, acute interventions frequently have to be put in place immediately to reduce the risk of suicide attempts or self-harm. Using the acute-on-chronic model can be very effective for communicating decisions regarding interventions.
For example, if a patient is assessed to be at a chronic but not acute-on-chronic risk for suicide, one can document and communicate that a short-term hospital admission will have little or no impact on a chronic risk that has been present for months or years. However, an inpatient admission of a patient demonstrating an acute-on-chronic risk would be well indicated (Links et al., 2003). In this circumstance, a short-term admission may allow the risk level to return to the chronic, pre-admission level. Managing the chronic level of suicide risk in patients with BPD often involves strategic outpatient management such as dialectical behavior therapy, which has been shown to be effective in reducing suicidal behavior (Koerner and Linehan, 2000; Linehan, 1993).