Patients with borderline personality disorder are at a much higher risk for suicide attempts than patients with almost any other mental illness. Here, a case report and examples are presented to help clinicians assess, diagnose and treat patients with BPD who have attempted or are threatening suicide.
"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.
Family and Social History
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.
Assessing Suicide Risk
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).
Using this model of suicide risk assessment, Anita clearly demonstrated an acute-on-chronic risk for suicide, as indicated by high levels of hopelessness, recent alcohol and drug abuse, recent discharge from hospital, several recent negative life events, and a perception that her support system had given up on her. If the patient is at an elevated risk, the next question is whether hospitalization will be helpful or harmful. When considering this question for Anita, we suggest that you consider some common myths about admitting the patient with BPD.
Myth 1: Hospitalization is never useful for patients with borderline personality disorder. Hospitalizations and multiple service contacts are part of the expected course of this disorder (Bender et al., 2001; Zanarini et al., 2004). It would be fallacious to argue that patients with BPD should never be hospitalized. There is little empirical evidence about whether hospitalization prevents suicide for these or any other patients at risk, and such tenets are difficult to prove primarily because suicide is a rare outcome.
Myth 2: Patients with BPD will regress during their inpatient stay. With the reality of only brief hospitalizations, patients who show disruptive and unsafe behaviors, including self-harm behaviors, during an inpatient stay are likely continuing in a long-standing pattern of impulsive aggressiveness rather than regressing to behaviors not typical of their repertoire (Boggild et al., 2004). Patients with few external sources of support or those without housing are at increased risk for disruptive behavior during a hospitalization (Boggild et al., 2004). Patients with BPD may be disruptive and demonstrate unsafe behavior during a hospitalization. However, being disruptive does not necessarily mean that these patients have not derived benefit from their inpatient stay. Discussions of personal safety as a mutual responsibility for the patient, other patients and staff should be an integral part of therapy, both in and out of the hospital.
Myth 3: The patient's crisis has to do with their doctor being "fed up" with them. Countertransferential and transferential problems are characteristic of therapy, and it is to be expected that such issues will lead to crises and presentations to the emergency department. Crisis services and hospital inpatient services can have an important and sometimes life-saving role in resolving or attenuating these crises.
Anita was admitted to the hospital for a few days. Rather than perceiving her admission as a therapeutic setback, we noted that this presentation was one of the only times she had presented without first cutting herself deeply. Her story is continuing, but she is alive and still insisting on our help and understanding.
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.