Managing Suicidality in Patients With Borderline Personality Disorder

Suicidality is a defining feature of borderline personality disorder (BPD). It is also the feature that creates the most anxiety among those who treat patients with this disorder. It is rare to find patients with BPD who have never shown any suicidal behavior. As described in criterion 5 in DSM-IV-TR,¹ these patients are characterized by "recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior." Suicidal ideas and threats are ubiquitous, and most patients make multiple suicide attempts.² Suicidality in patients with BPD is chronic and can continue for extended periods (months to years).^3,4 This feature helps distinguish patients with BPD from those with classic mood disorders, who are suicidal only when acutely depressed. While BPD often begins with repetitive suicide attempts starting in adolescence and continuing into young adulthood, these behaviors tend to remit over time.^5,6 Suicidal thoughts vary in intensity over time, waxing when life is stressful and waning when it is not.⁷

Suicidality in patients with BPD is associated with traits of affective instability. ^8-10 Instead of continuous depression or mania, lasting for weeks to months, the rapid mood swings of BPD occur in response to life events.¹¹ The unique quality of these symptoms is shown by the failure of mood in BPD to respond consistently to antidepressants.^12-14 Suicidal actions are also associated with impulsive personality traits.³ Soloff and associates² reported a mean of 3 lifetime attempts in patients with BPD, and the frequency of attempts was related to levels of impulsivity.^2,15

Suicide completion in BPD

Long-term naturalistic follow-up studies, with one exception,¹⁶ have shown that about 10% of patients with BPD eventually commit suicide and that about 90% do not.^17-20 Although 2 recent prospective studies report suicide rates closer to 4%,^21,22 these results may be limited to cohorts that were consistently compliant with treatment.

One of the most interesting findings that has emerged from long-term follow-up research in BPD is the age at which suicide completions occur. Threats and attempts peak early in the course of BPD, when patients are in their 20s, yet completion occurs much later. Thus, patients with BPD do not usually kill themselves at the time when they most alarm therapists, but later in development, usually if they fail to recover. In one follow-up study,¹⁷ the mean age of patients who completed suicide was 30, while in another,¹⁹ it was 37 (SD, ± 10). Clinicians should also keep in mind that since completions are rare relative to attempts, it is almost impossible to predict suicide in individual cases.^23,24

The meaning of suicidality in BPD

In BPD, the most typical suicidal behavior is an overdose of pills, occurring in an interpersonal context.²⁵ These overdoses usually carry a message-sometimes for a lover and sometimes for a therapist. Patients with BPD also tend to cut their wrists repetitively, and/or carry out other actions to hurt themselves. ²⁶ However, self-mutilation is not truly suicidal behavior. It typically consists of superficial cuts on the wrists and arms, and patients report that it functions to provide short-term regulation of intense dysphoric affects.^9,27 Self-mutilation can come to resemble addictive behavior.

Suicidal ideas and actions in patients with BPD perform several functions.⁹ The first is providing a sense of control. If one cannot master one's life, one can at least choose to die or threaten to die. The second is offering a comforting option of escape from pain and suffering. The third is communicating distress. Patients with BPD do not expect to be readily heard by others, and often feel they need to demonstrate the depth of their suffering in a concrete fashion.

The management of chronic suicidality

Borderline patients tend to be unpopular with therapists because their suicidality is frightening. Therapists may be concerned about the threat of litigation if a suicide should occur.²⁸ However, in patients with BPD, suicidality "goes with the territory"²⁹ and should be seen as another type of problem, in the same way as psychosis.

The main point to keep in mind is not to apply management strategies designed for acute suicidality to chronic suicidality.³⁰ Active interventions designed to prevent suicide have a tendency to be counterproductive in patients with BPD because they reinforce the very behaviors they are designed to treat.⁹ Most BPD experts have advised therapists to tolerate suicidality and focus on the problems that cause it. Kernberg³¹ recommends that therapists inform patients and their families that they cannot take responsibility for, or ultimately prevent, completed suicide; and Maltsberger³² argues that one must accept a calculated risk to effectively treat patients with BPD.

Many believe that, if possible, hospitalization should be avoided. Linehan⁹ sees hospitalization as interfering with effective treatment and is only willing to tolerate an overnight hospital stay. Livesley³³ advises keeping hospitalization to a rarity. Dawson and MacMillan³⁴ suggest that hospitalization should almost never be used for patients with BPD. Gunderson,²⁵ while not excluding admission, tries to avoid it by informing patients that it will not be helpful. The American Psychiatric Association guideline for the treatment of borderline personality disorder represent a committee consensus and take a different point of view.³⁵ The guideline (page 8) states, "When the patient's safety is judged to be a serious risk, hospitalization may be indicated." Yet there is no evidence that such interventions actually increase safety or reduce mortality. Moreover, when suicidality is chronic, hospitalization tends to become recurrent.³⁶ Thus while hospital admission may provide temporary relief, most patients continue to have suicidal ideas after discharge. Hospitalization can also be harmful when recurrent admissions disrupt the patient's life.³ There is a good evidence-based alternative. Clinical trials of outpatient treatment support its use for patients with BPD in crisis.³⁷ Day hospitals have the advantages of intensive treatment by an experienced team without the disadvantages of a full inpatient admission.

Most patients with BPD are managed as outpatients with psychotherapy.³⁸ It is also common to use pharmacotherapy as an adjunct to reduce impulsivity, 14 but there is no evidence that drugs can prevent suicide. The key to effective psychotherapy in BPD may be to address the life issues that make patients consider ending their lives rather than making an endless cycle of attempts to prevent suicide.³⁹ Dialectical behavior therapy (DBT) is an effective method for reducing levels of parasuicidal behavior.⁹ DBT uses specific strategies to manage suicidality: therapists conduct a behavioral analysis in which they validate the distress behind suicidal ideas, identify the problems leading to that distress, and work to develop alternative solutions to these problems. Instead of reinforcing suicidality through increased therapist contact (a common problem in other therapies), DBT offers brief coaching through telephone contact when patients communicate thoughts but provides negative reinforcement (temporary loss of sessions) of suicidal actions. Recently, several other promising forms of therapy, including mentalization- based treatment, transferencefocused therapy, and schema therapy have undergone clinical trials.¹⁴ Suicidality in BPD remits when patients attain meaningful work and establish a network of relationships.⁴⁰ The long-term follow-up studies reviewed above show that most recovered patients are working, about half achieve some kind of stable relationship, and about a quarter raise children, although formal research has not determined whether the offspring of patients with BPD are also at risk.⁶

Conclusions

The management of suicidality in patients with BPD is anxiety provoking. Yet fear need not paralyze therapists or lead them to avoid these patients. Research suggests that most people with BPD get better with time, and that patients in crisis are not at high risk for suicide completion. The focus of therapy should be on problem solving and improved functioning, with the ultimate goal of supporting reasons for living.

Dr Paris is a professor in the department of psychiatry at McGill University and a researcher at the Institute of Community and Family Psychiatry of the Sir Mortimer B. Davis- Jewish General Hospital in Montreal, Quebec. He reports that he has no conflicts of interest concerning the subject matter of this article.

References

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association; 2000.
2. Soloff PH, Lynch KG, Kelly TM, et al. Characteristics of suicide attempts of patients with major depressive episode and borderline personality disorder: a comparative study. Am J Psychiatry. 2000;157:601- 608.
3. Paris J. Chronic suicidality among patients with borderline personality disorder. Psychiatr Serv. 2002;53:738-742.
4. Paris J. Half in love with easeful death: the meaning of chronic suicidality in borderline personality disorder. Harvard Rev Psychiatry. 2004;12:42-48.
5. Paris J. Personality Disorders Over Time. Washington, DC: American Psychiatric Association; 2003.
6. Maris RW, Berman AL, Silverman MM. Comprehensive Textbook of Suicidology. New York: Guilford Press; 2000.
7. Grilo CM, McGlashan TH, Skodol AE. Stability and course of personality disorders: the need to consider comorbidities between axis I psychiatric disorders and axis II personality disorders. Psychiatr Q. 2000;71:291-307.
8. Koenigsberg HW, Harvey PD, Mitropoulou V, et al. Characterizing affective instability in borderline personality disorder. Am J Psychiatry. 2002;159: 784-788.
9. Linehan MM. Cognitive Behavioral Therapy of Borderline Personality Disorder. New York: Guilford Press; l993.
10. Siever LJ, Davis KL. A psychobiological perspective on the personality disorders. Am J Psychiatry. 1991;148:1647-1658.
11. Gunderson JG, Phillips KA. A current view of the interface between borderline personality disorder and depression. Am J Psychiatry. l99l;48:967-975.
12. Shea MT, Pilkonis PA, Beckham E, et al. Personality disorders and treatment outcome in the NIMH Treatment of Depression Collaborative Research Program. Am J Psychiatry. 1990;147:711-718.
13. Soloff P. Psychopharmacology of borderline personality disorder. Psychiatr Clin North Am. 2000;23:169-192.
14. Paris J. Recent advances in the treatment of borderline personality disorder. Can J Psychiatry. 2005;50:435-441.
15. Brodsky BS, Malone KM, Ellis SP, et al. Characteristics of borderline personality disorder associated with suicidal behavior. Am J Psychiatry. 1997;154:1715-1719.
16. McGlashan TH. The Chestnut Lodge follow-up study, III: long-term outcome of borderline personalities. Arch Gen Psychiatry. 1986;43:20-30.
17. Stone MH. The Fate of Borderline Patients. New York: Guilford Press; 1990.
18. Paris J, Brown R, Nowlis D. Long-term followup of borderline patients in a general hospital. Compr Psychiatry. 1987;28:530-535.
19. Paris J, Zweig-Frank H. A twenty-seven year follow-up of patients with borderline personality disorder. Compr Psychiatry. 2001;42:482-487.
20. Kullgren G. Factors associated with completed suicide in borderline personality disorder. J Nerv Ment Dis. 1988;176:40-44.
21. Zanarini MC, Frankenburg FR, Hennen J, Silk KR. The longitudinal course of borderline psychopathology: 6-year prospective follow-up of the phenomenology of borderline personality disorder. Am J Psychiatry. 2003;160:274-283.
22. Skodol AE, Gunderson JG, Shea MT, et al. The Collaborative Longitudinal Personality Disorders Study (CLPS): overview and implications. J Personal Disord. 2005;19:487-504.
23. Goldstein RB, Black DW, Nasrallah A, Winokur G. The prediction of suicide: sensitivity, specificity, and predictive value of a multivariate model applied to suicide among 1906 patients with affective disorder. Arch Gen Psychiatry. 1991;48:418-422.
24. Pokorny AD. Prediction of suicide in psychiatric patients: report of a prospective study. Arch Gen Psychiatry. l983;40:249-257.
25. Gunderson JG. Borderline Personality Disorder: A Clinical Guide. Washington, DC: American Psychiatric Association; 2001.
26. Simeon D, Stanley B, Frances A, et al. Selfmutilation in personality disorders: psychological and biological correlates. Am J Psychiatry. 1992;149: 221-226.
27. Brown MZ, Comtois KA, Linehan MM. Reasons for suicide attempts and nonsuicidal self-injury in women with borderline personality disorder. J Abnorm Psychol. 2002;111:198-202.
28. Gutheil TG: Suicide and suit: liability after selfdestruction. In: Jacobs D, ed. Suicide and Clinical Practice. Washington, DC: American Psychiatric Association; 1992:147-167.
29. Schwartz DA, Flinn DE, Slawson PF. Treatment of the suicidal character. Am J Psychother. 1974;28:194-207.
30. Fine MA, Sansone RA. Dilemmas in the management of suicidal behavior in individuals with borderline personality disorder. Am J Psychother. 1990;44:160-171.
31. Kernberg OF. Diagnosis and clinical management of suicidal potential in borderline patients. In: Grotstein JS, Solomon MF, eds. The Borderline Patient: Emerging Concepts in Diagnosis, Psychodynamics and Treatment. New York: Analytic Press; 1987:69- 80.
32. Maltsberger JT. Calculated risks in the treatment of intractably suicidal patients. Psychiatry. 1994; 57:199-212.
33. Livesley WJ. The Practical Management of Personality Disorder. New York: Guilford Press; 2003.
34. Dawson D, MacMillan HL. Relationship Management of the Borderline Patient: From Understanding to Treatment. New York: Brunner/ Mazel; 1993.
35. American Psychiatric Association Practice Guidelines. Practice guideline for the treatment of patients with borderline personality disorder. Am J Psychiatry. 2001;158(suppl):1-52.
36. Hull JW, Yeomans F, Clarkin J, et al. Factors associated with multiple hospitalizations of patients with borderline personality disorder. Psychiatr Serv. 1996;47:638-641.
37. Bateman A, Fonagy P. Effectiveness of partial hospitalization in the treatment of borderline personality disorder: a randomized controlled trial. Am J Psychiatry. 1999;156:1563-1569.
38. Bongar B, Maris RW, Berman AL, Litman RE. Outpatient standards of care and the suicidal patient. In: Bongar B, Berman AL, Maris RW, et al, eds. Risk Management With Suicidal Patients. New York: Guilford Press; 1998:4-33.
39. Paris J. Managing the Chronically Suicidal Patient: Half in Love With Easeful Death. Mahwah, NJ: Laurence Erlbaum; 2006.

Evidence-based References

• Brown MZ, Comtois KA, Linehan MM. Reasons for suicide attempts and nonsuicidal self-injury in women with borderline personality disorder. J Abnorm Psychol. 2002;111:198-202.

• Soloff PH, Lynch KG, Kelly TM, et al. Characteristics of suicide attempts of patients with major depressive episode and borderline personality disorder: a comparative study. Am J Psychiatry. 2000;157:601- 608.