Making the diagnosis
The first step in managing suicide risk in patients with BPD is to correctly identify the disorder. After multiple encounters that end in feeling manipulated or duped, physicians often come to assign the diagnosis of BPD only to patients whom they dislike or view as attention-seeking. Despite the importance of this diagnosis, physicians do not usually screen for BPD because making an accurate diagnosis can be time-consuming; they often come to believe that they can magically sense whether or not BPD is present.
Underdiagnosis of BPD is common, as is a misdiagnosis of bipolar disorder.8 Some indicators for systematic diagnostic screening for BPD include meeting criteria for multiple Axis I conditions; taking 3 or more psychiatric medications; or having evidence of behavioral dyscontrol, such as an eating disorder, substance use disorder, or recurrent incidents of self-harm. Routine use of brief self-rating scales, such as the McLean Screening Instrument for Borderline Personality Disorder9 and the patient questionnaire portion of the Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II),10 can also greatly enhance diagnostic accuracy.
The conflict within health care providers over whether their patient’s suicidal behavior and threats are legitimate mirrors a similar conflict within patients with BPD over whether their illness is legitimate, or whether they are totally to blame for their problems, attention-seeking, and needing to get their act together. Patients can rapidly switch states as they take one side of the conflict or the other, switching blame from self to others. Assessing the patient’s current state of being, recent stressors, alcohol(Drug information on alcohol) misuse, and support system informs the health care provider about immediate risk. The Table provides some management strategies to minimize risk of suicide.
Table: Management strategies to minimize suicide risk in BPD
Consultant to the emergency department
• Look for triggers of suicidal ideation or behavior, especially abuse, separation, or loss; are these time-limited or on-going? Ask yourself what has changed between the time of the overdose and the present to lower the risk of suicide? Consider hospitalization if there have been no changes.
• When eliciting the history, look to see whether the patient is placing blame for current difficulties onto self or onto others: the first is strongly suggestive of the guilty perpetrator state and higher suicide risk; the second is suggestive of the angry victim state and lower suicide risk.
• Treat the patient with care and respect; sarcastic comments or a dismissive attitude can increase the risk for suicide or for aggressive behavior.
• Ultimately, the consultant may face a dilemma: discharge may be perceived as abandonment, whereas admission may lead to regression; either action can potentially increase suicide risk.11 It is usually helpful to convey this dilemma to the patient—he or she is more likely to assume an adult, responsible role if included in the decision-making process.
• Hospital stays should be kept short to minimize regression, generally a few days to a week.
• The goals of inpatient stays are brief stabilization, preparation for outpatient treatment, and consultation with the outpatient therapist. Ask the patient about patient-therapist boundaries and the nature of the relationships outside of therapy, especially issues of abuse, rejection, loss, and separation. Use motivational interviewing to build autonomous motivation for inpatient and outpatient treatment; a family meeting can help clarify possible precipitating factors for the admission.
• Excessive focus on co-occurring Axis I disorders and pharmacotherapy may worsen regression by fostering a passive sick role. Patients with Axis I disorders tend to respond poorly to usual treatment strategies when co-occurring borderline personality disorder (BPD) is present.12
• Avoid benzodiazepines to manage patient anxiety. Patients tend to like benzodiazepines and often describe them as the only medications that are helpful; however, benzodiazepines have been shown to worsen behaviors and mood dysregulation.13
• Patients provoke strong urges in health care providers to either adopt a nurturing role or be dismissive and scornful (the patient is just attention-seeking). Often, inpatient health care providers become split into opposing camps14; educate team members about this dynamic and about the causes of suicidal behaviors in this population.
• Manual-based treatments, such as dialectical behavior therapy,15 dynamic deconstructive psychotherapy,16 mentalization-based treatment,17 and transference-focused psychotherapy,18 are often much more effective than relying on clinical intuition and judgment in an eclectic, unstructured model.
• The most effective treatments for BPD strongly emphasize the importance of clear boundaries between patient and therapist and frequent case consultation with other therapists. Staying within the treatment frame can be extremely challenging with patients who have BPD, since they tend to evoke strong reactions in health care providers, both positive and negative.
• Encourage patients to take responsibility for maintaining their own safety and making a commitment to work toward recovery; this can be instituted as part of reviewing written treatment goals and expectations early in treatment.
• The single most effective technique to improve dissociation and core symptoms of BPD is to get patients to verbalize recent upsetting interpersonal experiences, create sequential narratives of these experiences, and label associated emotions.
Staying empathic and keeping the conflict within the patient instead of between the patient and health care provider, is a key to successful management. Other keys include maintaining clear expectations and boundaries, building autonomous motivation, and helping patients verbalize experiences and emotions.