Needs Assessment: Borderline personality disorder (BPD) is a psychiatric disorder often associated with suicidal behavior, thoughts, and urges. Primary care physicians are very likely to encounter and treat individuals with BPD and, therefore, need to be educated about the characteristics, risk factors of suicidality, and treatment options in individuals with BPD.
• Recognize risk factors for suicidal behavior that should be considered and assessed in patients with BPD.
• Identify treatment options for patients with BPD who are at risk for suicidal behavior.
Target Audience: Primary care physicians and psychiatrists.
Credit Designation: The Mount Sinai School of Medicine designates this educational activity for a maximum of 3 AMA PRA Category 1 Credit(s)TM. Physicians should only claim credit commensurate with the extent of their participation in the activity.
This activity has been peer-reviewed and approved by Eric Hollander, MD, chair and professor of psychiatry at the Mount Sinai School of Medicine, and Norman Sussman, MD, editor of Primary Psychiatry and professor of psychiatry at New York University School of Medicine. Review Date: October 25, 2007.
To receive credit for this activity: Read this article and the two CME-designated accompanying articles, reflect on the information presented, and then complete the CME posttest and evaluation. To obtain credits, you should score 70% or better. Early submission of this posttest is encouraged: please submit this posttest by December 1, 2009 to be eligible for credit. Release date: December 1, 2007. Termination date: December 31, 2009. The estimated time to complete all three articles and the posttest is 3 hours.
Dr. Fertuck is assistant professor of clinical psychology in the Department of Psychiatry at Columbia University College of Physicians & Surgeons and the New York State Psychiatric Institute in New York City. Ms. Makhija is assistant research scientist at Columbia University. Dr. Stanley is director of the Suicide Intervention Center at the New York State Psychiatric Institute/Columbia University College of Physicians & Surgeons.
Disclosure: The authors report no affiliation with or financial interest in any organization that may pose a conflict of interest.
Funding/support: This article was supported in part by grants from the American Foundation for Suicide Prevention (AFSP), the Fund for Psychoanalytic Research through the American Psychoanalytic Association, and the National Institute of Mental Health (NIMH; 1 K23 MH077044-01A2) to Dr. Fertuck; and in part by grants from the AFSP, the NIMH (R01 MH061017 and MH62665), and the National Institute on Alcohol Abuse and Alcoholism (P20 AA015630) to Dr. Stanley.
Borderline personality disorder (BPD) is a common but often misunderstood and stigmatized psychiatric condition. Furthermore, BPD is a psychiatric disorder associated with one of the highest rates of healthcare utilization. Accordingly, the prevalence of BPD in primary care settings is high. The most pressing and lethal dimension of BPD is suicidal behavior. There is an almost 10% rate for suicide completion in BPD, which is 400 times greater than the rate in the general population. Primary care physicians (PCPs) are very likely to encounter and treat individuals with BPD at risk for suicide. However, most PCPs have not been educated about this diagnosis. This article aims to orient and familiarize PCPs with the unique characteristics and risk factors of suicidality and treatment options for individuals with BPD.
This article has two aims. First, to orient and familiarize primary care physicians (PCPs) with the unique characteristics and risk factors of suicidality in borderline personality disorder (BPD).1 Second, to inform PCPs about treatment options for suicidal individuals with this diagnosis. Given the prevalence and high rate of healthcare utilization associated with BPD, it is likely that in their day-to-day clinical work, PCPs in both psychiatric and other primary care settings will encounter individuals with BPD, some of whom may be acutely suicidal. Consequently, it is essential that PCPs understand the symptomatic manifestations and treatment options for suicidal individuals with BPD.
Prevalence of Borderline Personality Disorder
BPD is a common but often misunderstood and stigmatized psychiatric condition. Up to 2.8 million adults in the United States meet criteria for BPD,2 approximately three times higher than the rate of schizophrenia.3 In clinical settings, most individuals with BPD are women; however, in the general population the gender ratio appears equal.2 This suggests that more women than men with BPD seek treatment in psychiatric settings.
Characteristics of Borderline Personality Disorder
Individuals with BPD are profoundly sensitive to perceived abandonment, rejection, and betrayal by significant others. Further, stormy and turbulent emotional states tend to occur in the context of perceived disruption and threats to relationships with significant others. Consequently, the relationships of those with BPD are often fraught with conflict, anger, and disappointment. Individuals with BPD also have impairments in regulating and modulating their intense emotional experiences. For these individuals, emotions can quickly spiral out of control, leading to intense states of anxiety, tension, and anger. Concurrently, disruption in the sense of self or identity is frequent in individuals with BPD. Accordingly, many people with BPD struggle with a chronic sense of emptiness and alienation. Individuals with BPD tend to view themselves critically and to expect to be emotionally hurt by others. Poor impulse control is a core feature of BPD. Impulsive behavior in BPD is most often self-directed and takes the form of suicide attempts, non-suicidal self-injury (NSSI; such as cutting), substance abuse, and high-risk behaviors (such as reckless driving). When emotionally stressed, dissociation and brief psychotic-like symptoms can occur. The psychotic-like symptoms do not take the form of hallucinations seen in schizophrenia. Rather, they are usually the product of interpersonal sensitivity and are exaggerations of the perceived hurtful intentions of others.
Suicide Completion in Borderline Personality Disorder
The high rate of completed suicide in major depressive disorder (MDD), bipolar disorder, and schizophrenia is well recognized by most clinicians. However, there is not yet widespread appreciation that the nearly 10% rate for suicide completion in BPD is comparable to these other disorders4-10 and is 400 times greater than the rate in the general population. Of all completed suicides, 9% to 33% are by individuals with BPD.11,12 Moreover, 60% to 84% of patients with BPD have made at least one suicide attempt,13,14 indicating that attempts outnumber completions by approximately 8 to 1.
Assessing Suicide Risk in Borderline Personality Disorder
There are several risk factors for suicide in BPD, some of which are unique to this patient population. Regrettably, none of these factors allow clinicians to confidently predict risk for completed suicide. Nonetheless, the following sections summarize the risk factors that the PCP should consider and assess when attempting to identify and prevent suicide attempts in patients with BPD.
Many clinicians are reluctant to ask patients direct question about suicide out of concern that it may actually trigger an attempt. There is no evidence for this concern.15 On the contrary, not assessing the possibility of suicidality may lead to a preventable suicide attempt. With individuals with BPD, a thorough, calm, and concerned inquiry of suicidality is required.
Differentiating Suicidal Behavior from Non-Suicidal Self-Injury in Borderline Personality Disorder
For clinicians, one of the most confusing features of BPD is NSSI and self-injury with only partial suicidal intent (see Posner and colleagues16 for a typology of suicidal behavior). Most individuals with BPD have cut, burned, hit, or otherwise injured themselves at some point in the course of their illness. For many, this is a frequent, recurrent behavior. Less obvious forms of self-injury include impulsive substance use, over- or under-eating, risky driving, and high-risk sexual behavior. The most common reported motivations for these behaviors among individuals with BPD are self-punishment as a consequence of extreme anger and self-hatred, to interrupt dissociative symptoms and to feel “real,” to communicate distress, to avoid making a suicide attempt, to reduce unbearable negative emotions (usually manifest as anxiety or tension), and to restore a sense of emotional equilibrium (ie, “to feel better”).17
NSSI and suicide attempts and completions often co-occur; however, those patients with both may be a unique sub-population.18 Suicide attempters with cluster B personality disorders such as BPD who also have a history of NSSI tend to exhibit more depressive symptoms, anxiety, and impulsivity. As a result, clinicians may assess the suicide risk of those who engage in NSSI as less serious than it actually is.18
Individuals who present with BPD and NSSI need to be assessed for the degree of suicidal intent associated with this behavior. NSSI doubles a BPD patient’s risk for suicide.19 With this in mind, individuals with BPD often underestimate the lethality and danger of NSSI and may put their lives at risk without full intent.20 Furthermore, clinicians treating an individual with repeated NSSI may overlook genuine suicidal intent when it occurs. If the individual with BPD has NSSI without acute suicidal intent and this is low in lethality and risk, then specialized outpatient treatment for BPD is indicated (see below). Given the high rate of treatment non-compliance, recommendations for specialized treatment should be followed up with an inquiry to the patient and with consistent encouragement to seek treatment for this behavior. While it is outside the scope of this paper to focus on primary care intervention for NSSI, others have recommended an approach for use in the psychiatric emergency room.21
Differentiating Chronic Suicidal Ideation from Acute Suicidal Intent and Risk
Individuals with BPD often have chronic suicidal ideation. For some, chronic suicidal ideation with recurrent attempts and self-injurious behaviors becomes a “way of life” that seems to allow these individuals to cope with emotions and life circumstances that feel intolerable and uncontrollable. While distressing to these patients and those around them, suicidal ideation without acute suicidal intent, a plan, and realistic means (eg, the availability of a firearm) can best be addressed in specialized outpatient or partial hospital treatment.
The Importance of Interpersonal Context and Experience in Suicidality in Borderline Personality Disorder
In keeping with the interpersonal turbulence associated with BPD, environmental triggers of highly lethal suicide attempts by people with BPD and MDD are more likely to be interpersonal stressors than in patients with MDD alone.22 Despite this difference, lethality of attempts in BPD is equal to that of MDD, indicating that the type of precipitant is unrelated to the lethality of the suicidal behavior. It is crucial for the clinician to inquire about environmental triggers to suicide, both perceived and actual, when evaluating suicidality, particularly in BPD.
Other Co-Occurring Disorders that Increase Suicide Attempt and Completion Risk in Borderline Personality Disorder
The presence of several other Axis I and II psychiatric disorders can also increase suicide risk in BPD. The most concerning is a current or past substance use disorder.23-27 Whether or not the patient meets criteria for a current substance use disorder, substance abuse prior to an attempt can disinhibit individuals who may be ambivalent about suicide, leading to more lethal attempts. Substance abuse can impair judgment so that suicidal actions instigated with a low level of intent can result in lethal consequences. Further, substance use disorders which may be linked to the trait of impulsivity—a suicide risk factor even after substance abuse or MDD is controlled for—are associated with increased lifetime suicide attempts in patients with BPD.20,26,28
Co-occurring MDD and other mood disorders are common in BPD. However, the quality of the mood disturbance is different from MDD without BPD.29 Suicide attempters with co-occurring BPD and MDD have more lifetime suicide attempts, make their first attempt at a younger age, report more interpersonal triggers to attempts, and have higher levels of lifetime aggressive behaviors, hostility, and impulsivity compared with depressed attempters without BPD.22 In BPD, depressive moods and affects are reactive to interpersonal and other environmental stressors and are usually of briefer duration. By contrast, in MDD, the severity of depression and suicidality build up more gradually and can persist for weeks or months. Suicide attempts in MDD, then, are often done in a planned manner after extended dysphoric periods that conclude in a sense that the only option is to end one’s life.30
Consequently, the impact of depression severity on suicide is less clear in BPD than in MDD. In one study, emotional dysregulation in BPD was the strongest predictor of prospectively assessed suicidal behaviors and suicide attempts; severity of depression at baseline did not predict later suicidality.31 However, current severity of MDD is associated with increased risk for a greater number of suicide attempts that are more lethal in BPD.23,28,32 Moreover, sub-threshold depressive symptoms and hopelessness can increase suicide attempt risk in BPD. Consequently, assessment of the severity of current depressive symptoms is crucial when assessing suicide attempt risk in BPD.
The majority of suicide victims with antisocial personality disorder have co-occurring BPD. Moreover, the more individuals with BPD have characteristics of antisocial personality, the greater their risk for making suicide attempts. Though the risk of suicide associated specifically with antisocial personality disorder remains unclear, it is estimated that the lifetime suicide risk associated with this diagnosis is 5%.20,23,25
Other Risk Factors
Other risk factors for suicidal behavior in BPD include prior suicide attempts25,27,33-35 and having past suicide attempts of high medical lethality.27,36 However, these risk factors are not unique to BPD. A younger age, most specifically from adolescence through the third decade of one’s life,26 is associated with increased suicide risk in BPD. However, some have proposed that more suicide attempts occur at a younger age, whereas more suicide completions occur between 30 and 37 years of age. This may be due to increased hopelessness as treatments have failed the individual. A history of sexual or physical abuse is a strong risk factor for suicide attempts as well.14,20 Other family and developmental factors such as parental absence or separation during childhood, employment or financial problems, or a lack of a permanent home in early life are associated with suicide attempts in BPD. Finally, prior hospitalizations33 and a higher level of education9 have been linked to suicide attempts in BPD.
Treatment of Borderline Personality Disorder
It is estimated that 11% of all psychiatric outpatients and 19% of psychiatric inpatients meet diagnostic criteria for BPD.37 One study38 found that individuals with BPD make up only 1% of the patient population seen in the psychiatric emergency room yet accounted for 12% of all visits. Moreover, the prevalence of BPD in primary care is high (6.4%), approximately four times higher than that found in general community studies.39 Accordingly, BPD is a psychiatric disorder associated with the highest rates of healthcare utilization.40
BPD is difficult to treat.41 Individuals with BPD are prone to feeling disappointed and angry with treatment providers as well as to ending treatment under the influence of unfulfilled expectations. The recurrent interpersonal difficulties, NSSI, and suicidality associated with BPD can lead clinicians to stigmatize BPD and feel burnt out and non-empathic toward BPD. Most mental health clinicians have no specialized training in working with this population. Without specialized training, clinicians often provide less than optimal assessment and care.
The Circumscribed Role of Hospitalization in Preventing Suicide in Borderline Personality Disorder
Most forms of suicidal behavior and NSSI in BPD can be managed and treated in an outpatient or partial hospital setting, provided such a treatment is in place. Even though the individual with BPD may desire and request hospitalization at times, regular hospitalization for suicidal threats, minor overdoses, and self-injurious behavior can actually reinforce these behaviors and be counter-therapeutic.42 Furthermore, because individuals with BPD are often chronically suicidal, much of their lives could be spent hospitalized if this was routinely employed. At the same time, the high suicide rate in BPD must be kept in mind and suicidal feelings should not be dismissed as simply threats.
Recommended Principles for Hospitalization in Borderline Personality Disorder with Suicidality
Specialized treatments for BPD have protocols for deciding when to hospitalize individuals with BPD. Primary therapists of individuals with BPD use their clinical judgment and the principles of their treatment approach to make a decision to hospitalize during an acute suicidal episode. As a result, close communication with the primary therapist is recommended before deciding to hospitalize an individual with BPD who is suicidal.
If an individual with BPD presents in a primary care setting with suicidality and he or she does not have a primary clinician with whom to immediately consult, the PCP is responsible for deciding whether hospitalization is warranted. There are discrete circumstances when brief inpatient treatment is necessary, such as when a patient with BPD appears to be at an extremely high risk for suicide and is not responding to therapy. Additionally, an acute episode of an Axis I condition such as MDD, bipolar disorder, or a psychotic disorder may require hospitalization to intensively evaluate and monitor the immediate effects of any treatment change.27,43
In general, if a patient reports the intent, plan, and available means for suicide attempt, they are at high risk for a suicide attempt and hospitalization is recommended. If the patient reports suicidal ideation without intent, plan, and means, then a “safety contract” (ie, an agreement between the clinician and patient that the patient will not harm him- or herself) and a treatment referral with a follow up call by the PCP to ensure the referral was utilized is recommended. In the event that a patient with BPD refuses a recommended hospitalization, involuntary admission may be necessary to ensure the patient’s immediate safety. For all decisions, thorough documentation of the decision and its clinical rationale is essential.
Manualized Psychosocial Treatments for Borderline Personality Disorder with Suicidality
Due to the complicated clinical picture and difficult-to-treat dimensions, BPD requires expert assessment and treatment, usually from a clinician or treatment team with specialized training. In the last 15 years, several manualized psychosocial treatments and medications now have varying empirical support in treating BPD from randomized controlled trials (RCTs). In addition, the American Psychiatric Association treatment guidelines for BPD were updated in 2005.44,45 All of the psychosocial treatments include strategies for managing and treating suicidality in BPD.
Dialectical-behavioral therapy (DBT) is a cognitive-behavioral treatment with two components, namely, individual therapy and weekly group skills training. The treatment balances “acceptance” and “change” strategies to help individuals with BPD improve emotion regulation capacities, and has a strong focus on helping individuals master skills to diminish suicidal urges and cope more effectively with their interpersonal relationships and emotional states. DBT has been found efficacious for reducing suicidal behavior, NSSI, and substance abuse in several RCTs.46
Cognitive-behavioral therapy (CBT) is a structured, time limited, individual treatment that focuses on altering core dysfunctional beliefs specific to BPD. In one RCT, CBT plus treatment as usual for BPD had better outcomes in suicide prevention and other symptom domains compared to treatment as usual without CBT.47
Schema-focused therapy (SFT), a modified form of CBT for personality disorders, posits the existence of schema modes (conceptions of self in relation to significant others) common and specific to BPD. The putative mechanism of change in SFT is to help the patient become less influenced by these pervasive schemas. In one RCT, this therapy demonstrated efficacy in multiple domains of symptoms and function, including suicidal behavior.48
Mentalization-based therapy (MBT) for BPD is a psychoanalytically oriented treatment in the context of a partial hospital program. MBT focuses on increasing “mentalization” in BPD. Mentalization entails making sense of the actions of oneself and others on the basis of intentional mental states such as desires, feelings, and beliefs. MBT has been found to be efficacious in reducing depression, suicidal acts, NSSI, inpatient days, and social functioning in one RCT.49,50
Transference-focused psychotherapy (TFP) is a psychoanalytic treatment rooted in object relations theory. TFP addresses disturbance in identity and conceptions of significant others in BPD. It is has received empirical support in one RCT, where it reduced self-injurious behavior comparably to DBT and more than supportive psychotherapy.51
Efficacy of Medication in Borderline Personality Disorder
No single pharmacologic agent has emerged as the treatment of choice for BPD.46,52 Moreover, medications for BPD have not been evaluated with a focus on their efficacy for reducing suicidal behaviors. As is often the case in psychopharmacology trials, the acutely suicidal patients are excluded. Thus, there is a pressing need to evaluate these agents for their efficacy in specifically reducing suicidal behavior, ideation, and intent. Prescribing medication to an acutely suicidal BPD patient with suicidality requires careful management and consideration and may be contraindicated if the prescribed medication can be used for a high lethality overdose.
Atypical neuroleptics show promise for reducing quasi-psychotic symptoms and the other dimensions of BPD,53 although their side effects, particularly weight gain, can make them unacceptable to patients. Placebo-controlled studies provide preliminary support for the efficacy of selective serotonin reuptake inhibitors (SSRIs) on mood dysregulation, irritability and hostility, and anxiety. Importantly, the relative efficacy of SSRIs, a common treatment for BPD, compared with psychosocial treatment has not been established. Mood stabilizers,54 particularly valproic acid55 and topiramate,56,57 and lamotrigine, show efficacy in the treatment of dimensions of BPD such as impulsive aggression.58 There is also support for the use of omega-3 fatty acids in the treatment of BPD,59 with better compliance, fewer side-effects, and less stigma than conventional mood stabilizers.
Case Vignettes Illustrating Suicidality and Non-Suicidal Self-Injurious Behavior in Borderline Personality Disorder
The following vignettes are examples of patients who have presented to the emergency department for suicide or NSSI. Included are a case with a suicide attempt and one with NSSI to illustrate the similarities and differences between these two clinical presentations. These two presentations have different treatment implications for the PCP.
Borderline Personality Disorder Suicide Attempter
The first vignette is of a patient with BPD who had multiple suicide attempts. This patient is illustrative of a BPD attempter because of the recurrent suicide attempts she has made throughout her life.
A 26–year-old Hispanic female who was separated from her husband and who had one daughter presented to a psychiatric emergency department with an angry and irritable mood. She complained of disturbed sleep, stating she had not slept in the past 2 weeks. At the same time she reported increased energy, distractibility, and having suicidal and homicidal ideation. She stated that she was “indifferent” as to whether she lived or died. She reported a history of physical and sexual abuse as a child. The patient had been unemployed for the last 4 months, receiving disability; prior to this she was working as a convenience store manager. She had nine lifetime suicide attempts and eight psychiatric hospitalizations that lasted between 1 week and 1 month. Four of her suicide attempts were overdoses (the first three attempts consisted of 25–30 pills each attempt). One of her attempts involved cutting her wrist with “little” cuts, and for one attempt she hung herself on a bus door for two seconds with a scarf before the scarf broke. Two of her attempts were interrupted (her friends stopped her from trying to jump in front of train tracks and trying to run into traffic), and one was aborted (she stopped herself before jumping into train tracks). Her most recent attempt was 3 weeks prior to the emergency room visit when she ingested 40 1-mg clonazepam capsules with the intent to die. The attempt was prompted by her feeling distraught after her husband moved away. After the overdose, she reported feeling dizzy and throwing up two or three times and then sleeping for 1.5 days.
The patient’s treatment history is as follows. She first began therapy at 7 years of age. Since 23 years of age she had eight psychiatric hospitalizations that lasted between 1 week and 1 month. She had been prescribed a variety of medication and at present is prescribed lithium carbonate and clonazepam but is non-compliant with these medications. She is not currently and had never been in any specialized treatment for BPD.
Borderline Personality Disorder Self-Injurer without Suicide Attempts
The second vignette is that of a woman with BPD who never had a suicide attempt but has had recurrent NSSI that she engages in impulsively when feeling upset. The patient sees this behavior as a way to feel more alive, release her tension, and punish herself. Note her underestimation of the medical risk and lethality inherent in her self-injury.
A 25-year-old Caucasian female brought herself to a psychiatric emergency department after cutting her right thigh with an Exacto knife. She stated that she became afraid of all the blood, realized that she had cut too deeply, and needed to get medical attention. She denied any suicidal ideation or intent. She has a history of sexual abuse by a family friend between the ages of five and seven. She reported no history of suicidal ideation in the last 2 years and no history of suicide attempts; she reported active suicidal ideation throughout her childhood with intent to act only once while sitting on a rooftop. On the roof she reported that she thought she would like to jump but a friend told her it was a bad idea. She had a history of NSSI. As a child she recalled jumping out of trees that were two stories high so she could hurt herself. She once tried to burn herself but stopped because of the pain. She has a history of picking the skin around her nails until it bleeds and of cutting herself on her arms, thighs, and stomach. She had stopped NSSI for some time in early adulthood, but resumed intermittently cutting herself 2 years ago. In the 2 months before presenting to the emergency room (ER), she had been cutting herself daily. She reported that she engages in superficial cutting because afterwards she “feels better, feels something and feels less numb” and that “it helps [her] sleep.” Her latest cutting episode stemmed from a phone call with her mother in which her mother told her she was too busy to speak with her. The patient reports that she was “mad at [her]self” because she felt that she was “hassling her mother.” Upon cutting herself this time she realized the cuts were much deeper than she normally made them and brought herself to the ER.
The patient’s treatment history is as follows. Her first experience with psychiatric treatment was for a few months when she was 8 years of age. She then began individual therapy again approximately 24 years of age. She had no prior psychiatric hospitalizations. She is currently in outpatient therapy and takes paroxetine 10 mg/day.
BPD is a serious disorder that puts an individual at increased risk for suicidal attempts and completions. The PCP is very likely to encounter individuals with this diagnosis in psychiatric and non-psychiatric settings, and suicidal behavior and urges may be present. It is crucial for the PCP to maintain an empathic and concerned clinical stance with individuals with BPD, in particular in the context of acute suicidality. A thorough assessment of suicidality in BPD focuses on suicidal intent, any suicidal plans, and the presence of a realistic means to complete the plan. Further, the degree of emotion dysregulation, interpersonal triggers to suicidality, and degree of suicidal versus non-suicidal intent in self-injurious urges and behaviors needs to be assessed to provide a complete picture of acute suicide risk. Given the complications that can arise in this multifaceted disorder, close communication and follow up with treatment providers who have expertise in the assessment and treatment of BPD is crucial as well. PP
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