Patients with borderline personality disorder (BPD) can present with multiple crises and minor incidents of self-harm or threats, but determining when the actions are true cause for concern can be a challenge. Assessing the patient’s current state of being, recent stressors, alcohol misuse, and support system can inform the health care provider about immediate risk. Similarly, below are suggested strategies that psychiatrists in various roles can employ to help reduce the risk of suicide. This Tipsheet is for quick reference only and not a replacement for the psychiatrist's experience and training, which are at the heart of what determines the severity of a psychiatric patient's condition. For further information, see Managing Suicide Risk in Borderline Personality Disorder Distinguishing Real Risk From Attention Seeking, from which this Tipsheet is adapted.
TIPSHEET: 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.1 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.2
• 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.3
• 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 camps4; educate team members about this dynamic and about the causes of suicidal behaviors in this population.
• Manual-based treatments, such as dialectical behavior therapy,5 dynamic deconstructive psychotherapy,6 mentalization-based treatment,7 and transference-focused psychotherapy,8 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.
1. Paris J. Is hospitalization useful for suicidal patients with borderline personality disorder? J Pers Disord. 2004;18:240-247.
2. Skodol AE, Grilo CM, Keyes KM, et al. Relationship of personality disorders to the course of major depressive disorder in a nationally representative sample. Am J Psychiatry. 2011;168:257-264.
3. Cowdry RW, Gardner DL. Pharmacotherapy of borderline personality disorder. Alprazolam, carba-mazepine, trifluoperazine, and tranylcypromine. Arch Gen Psychiatry. 1988;45:111-119.
4. Main TF. The ailment. Br J Med Psychol. 1957;30:129-145.
5. 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 dis-order [published correction appears in Arch Gen Psychiatry. 2007;64:1401]. Arch Gen Psychiatry. 2006;63:757-766.
6. Gregory RJ, DeLucia-Deranja E, Mogle JA. Dynamic deconstructive psychotherapy versus optimized community care for borderline personality disorder co-occurring with alcohol use disorders: 30-month follow-up. J Nerv Ment Dis. 2010;198:292-298.
7. Bateman A, Fonagy P. Randomized controlled trial of outpatient mentalization-based treatment versus structured clinical management for borderline personality disorder. Am J Psychiatry. 2009;166:1355-1364.
8. Doering S, Hörz S, Rentrop M, et al. Transference-focused psychotherapy v. treatment by community psychotherapists for borderline personality disorder: randomised controlled trial. Br J Psychiatry. 2010;196:389-395.