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Evidence-Based Reviews

Beyond threats: Risk factors for suicide in borderline personality disorder

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

Vol. 8, No. 5 / May 2009

Comment on this article

Manipulative, “just threats,” or suicide gestures are terms you may have heard or used to label suicidal thoughts and behavior in individuals with borderline personality disorder (BPD). These terms imply that the risk of injury or death is low, but evidence shows that BPD patients are at high risk for completed suicide 1-3 —and clinicians who use these labels may underestimate this risk and respond inadequately.

BPD is the only personality disorder to have suicidal or self-injurious behavior among its diagnostic criteria. 2 A prospective study showed a 3.8% completed suicide rate in a sample of borderline patients at 6-year follow-up. 2 Earlier studies reported rates from 8% to 10%—approximately 50 times greater than the general population. 1

Recent suicide attempts by individuals with BPD have shown:

  • the same degree of lethality and intent to die ( Box 1 ) 5-7 as recent suicide attempts by individuals without BPD 8
  • no differences in degree of intent to die compared with attempts by persons experiencing a major depressive episode or persons with both BPD and depression. 9

Moreover, patients with BPD (including those with comorbid depression) have reported greater lethality for their most serious life-time suicide attempt than those with depression alone. 9

Based on the literature and our clinical experience, this article offers recommendations for assessing and treating suicidal behavior in BPD patients. We review risk factors for suicide and suicide attempts and suggest strategies for safety management, psychotherapy, and pharmacotherapy. Because of the high-risk nature of this population, we recommend that all clinicians working with suicidal BPD patients obtain consultation and supervision as needed when using these strategies.

Box 1

Self-injury: Address all potentially harmful behaviors

Self-injurious behavior in borderline personality disorder (BPD) patients can be divided into 2 categories: suicide attempts and nonsuicidal self-injury.

  • Suicide attempts are performed with some evidence of intent to die. 5
  • Nonsuicidal self-injury behaviors (NSIB) are performed without intent to die. 6

How can clinicians respond effectively when suicidal behaviors are repetitive and performed both with and without the intent to die? Although patients may perform NSIB for reasons other than intent to die (such as to express anger, punish oneself, or relieve distress), 7 these behaviors require active intervention because of the possibility of serious injury (intentional or accidental). Also, the intent of a self-injurious behavior may change as the patient performs the behavior; what started as a nonsuicidal act may turn into a suicide attempt. 6 Therefore, address all potentially harmful behaviors.

Risk factors for suicidal behavior

Several risk factors for suicide attempts and completed suicide among individuals diagnosed with BPD have been identified. Previous suicide attempts are one of the strongest predictors of completed suicide and suicide attempts in individuals with BPD. 10-12 In general, clinicians cannot accurately predict which individuals will die by suicide. 10,13 Suicide risk factors identified in BPD ( Table 1 ) 12-16 are similar to those in persons without the BPD diagnosis. In BPD patients, risk factors for attempted and completed suicide largely overlap.

In a case-control study, BPD patients who died by suicide were reported by surviving relatives to have greater impulsivity and aggression and more comorbid diagnoses of antisocial personality disorder than control patients who did not commit suicide. 16 More prospective studies are needed to differentiate risk factors for suicide completion vs attempts.

Individuals with BPD may be distinguished by elevated risk factors for suicidal behavior as compared with suicide attempters without the BPD diagnosis. In a study comparing recent suicide attempters with and without BPD, those with BPD showed greater severity across a number of risk factors, including overall psychopathology, depression, hopelessness, suicide ideation, past suicide attempts, and social problem solving skills. 8

Table 1

Common risk factors for suicidal behavior in BPD

Behavioral factors
Previous suicide attempts
Poor social problem-solving skills
Poor social adjustment

Cognitive/emotional factors
Affective instability

Comorbid diagnoses
Major depressive disorder
Antisocial personality disorder
Substance abuse disorders

Psychosocial/psychiatric history
Childhood physical abuse
Childhood sexual abuse
Psychiatric hospitalizations

BPD: borderline personality disorder

Source: References 12-16

Remove lethal means

When working with patients with a history of suicidal behavior, it is critical to ensure the safety of the patient’s environment. Restricting access to lethal means has been shown to be an effective form of suicide prevention. 17 Direct all patients with a history of recent suicidality or nonsuicidal self-injurious behavior (NSIB) to remove lethal means and means of self-harm from their homes and possession ( Table 2 ). Continue to monitor access to lethal means throughout treatment, as patients may acquire new means or reveal possession of items they had previously concealed.

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.

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 suicide 18
  • Beck Depression Inventory (which contains a question about suicidal ideation). 28

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:

  • fear of hospitalization
  • uncertainty about whether or not they will attempt suicide
  • desire to conceal a planned suicide attempt.

In this situation, we suggest avoiding a prolonged interrogation or debate with the patient, which can make assessment even more confusing and harm the therapeutic relationship. Try to assess if other suicide risk factors are elevated, and use those to guide decision-making. Patients may be more forthcoming in self-report measures than in a verbal interview. For patients who often have difficulty quantifying their suicidality, an advance agreement can be useful (such as, “If you cannot accurately report your level of risk to me, I will take that as a sign you are in danger and need to be hospitalized”).

Hospitalize for suicidality?

If possible, consult with other professionals when making difficult decisions about hospitalizing a patient. These decisions often are subjective and open to influence by therapists’ emotional reactions. Psychotherapies for BPD emphasize the importance of consulting with other clinicians when working with this population. DBT requires a therapist consultation meeting, and cognitive therapies also have recommended consultation. 18-20

If you work alone in private practice, consider consulting by phone with colleagues experienced with working with BPD patients. Document this consultation to help protect yourself from liability should an adverse outcome occur.

Little evidence supports hospitalization as an effective treatment for suicidality in BPD. 24 It has been argued that hospitalization might increase future suicidal behavior when the patient perceives it as a positive experience or a means of escaping problems. 18 The patient’s safety must remain a top priority, however, and we recommend admission if the patient is in imminent danger or has engaged in self-injurious behavior requiring medical attention.

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