Beyond threats: Risk factors for suicide in borderline personality disorder

Current Psychiatry. 2009 May;08(05):33-41

May 1, 2009|Current Psychiatry

Michele S. Berk, PhD;Bernadette Grosjean, MD;Heather D. Warnick, PsyD

Removing immediate access to lethal means may give the patient time to reconsider a suicide attempt or nonsuicidal self-injury

We have found the following metaphor useful in discussing with patients the rationale for removing lethal means: “If you were on a diet, would it make sense to have a chocolate cake in the house?” Objections to removing lethal means often reveal important therapeutic issues. For example, those unwilling to relinquish lethal means may not be fully committed to giving up suicide or NSIB as an option. This would become a critical treatment goal.¹⁸

Tell patients to remove or discard fire-arms, knives, razors, and pills, as well as other items used in past suicide attempts/NSIB. Although patients can acquire new lethal means, removing immediate access lowers the possibility of an impulsive suicide attempt or NSIB and may give the patient time to reconsider.

Address overdose risk. Some physicians are reluctant or refuse to prescribe medication to BPD patients out of fear that it will be used to attempt suicide. A more productive approach is to ensure through informed choice of medications and strict management of their distribution that the patient safely and consistently receives necessary treatment.

Avoid prescribing psychiatric medications in quantities that could be lethal in overdose. Also determine whether the patient has other potentially lethal medications. If possible, have a friend or family member keep and administer the patient’s medications. If this is not possible, consider prescribing medications 1 week at a time.

Monitor as needed. If a patient continues to refuse to part with lethal means:

involve family members or friends in removing and monitoring the patient’s lethal means
assess the degree of imminent danger and if the individual can be safely managed as an outpatient.

Clinical Point

Every borderline personality disorder patient with a history of suicidality needs a detailed safety plan for what to do when suicidal

Monitoring and removal of lethal means are recommended until you feel confident the patient has obtained control over self-harm behaviors. Be sensitive about conveying distrust in the patient’s improvement when inquiring about access to lethal means when the patient is no longer experiencing suicidal thoughts or impulses. To avoid triggers of relapse, the most conservative approach may be for individuals with a history of suicidality to indefinitely restrict their access to lethal means. We find most patients accept this rationale and appreciate our concern for their safety.

Create a safety plan. Every BPD patient with a history of suicidality needs a detailed safety plan for what to do when suicidal ( Table 3 ).^19,20 Inform family members (and friends, when appropriate) of the safety plan, and involve them as needed to monitor a patient at risk. Give your BPD patients clear instructions about when you will be available by phone and emergency contacts for when you are not available.

Table 2

7 clinical tips for managing safety in BPD patients

Work with the patient in every session to remove all potentially lethal means (guns, knives, razors, pills) from his or her home and possession
Create a detailed safety plan to use during a suicidal crisis
Assess suicide risk in every session
Involve family and friends if possible to help monitor the patient and to call you or 911 if the patient appears to be in imminent danger of suicidal behavior
Create a ‘hope kit’ ( *Box 2* ) as a companion to the safety plan
Consider hospitalization if the patient is in imminent danger of suicidal behavior or has engaged in suicidal behavior requiring medical attention
Consult with other clinicians about crucial safety management decisions, such as whether or not to hospitalize a patient
BPD: borderline personality disorder

Table 3

Lifeline for suicidal patients: What to include in a safety plan

Warning signs of a suicidal crisis for that individual (such as increased depression or negative thinking)
Coping skills the patient can perform on his or her own
Family members and friends the patient can contact in an emergency
Therapist’s contact information
Phone numbers of emergency services available 24 hours daily (such as 911, suicide hotlines)
Source: References 19,20

Assess suicide risk

In every session, assess suicidal ideation, plans, intent, and urges to engage in NSIB. Consider using:

self-monitoring forms, such as a dialectical behavior therapy (DBT) “diary card,” on which the patient each day records urges to self-harm or attempt suicide¹⁸
Beck Depression Inventory (which contains a question about suicidal ideation).²⁸

Clinical Point

We recommend admission if the suicidal patient is in imminent danger or has engaged in self-injury requiring medical treatment

Also monitor use of psychiatric medications and substance use/abuse.^19-20

Risk assessment is not always straightforward. We have found that patients do not always provide consistent and/or accurate information about their degree of suicidality, making it difficult to know how to intervene. Reasons may include:

References

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