May 01, 2012 | By Robert J. Gregory, MD
Patients with borderline personality disorder (BPD) are often high users of health care and may present with multiple crises and minor incidents of self-harm or threats.1 As with the boy who cried wolf, inpatient consultants and health care providers may end up feeling manipulated and may not take suicide risk very seriously.
Ms A, a 22-year-old, was brought to the emergency department (ED) by ambulance; she had overdosed on zolpidem. After detoxification in the ED, a psychiatric consultation was requested. Ms A told the consultant that she had had a bad day and simply took 5 extra zolpidem tablets to “go to sleep” and that “it was just a stupid thing to do.” While obtaining the history, the consultant noted that Ms A’s therapist had left for vacation 2 days earlier.
The consultant informed Ms A that her overdose was just a reaction to her therapist’s vacation, that she did not have a major mental disorder, and that she was going to be discharged. In response, Ms A became irate, “No one cares about me; I just tried to kill myself and you just want to get rid of me! If you don’t admit me, I’m going to walk in front of the next bus!”
Feeling manipulated but with no other options, the consultant admitted Ms A to the inpatient psychiatric unit. Once there, the staff noted that Ms A seemed cheerful, childlike, and cooperative. In the morning, however, Ms A angrily demanded to be discharged when she was refused a smoking pass. The inpatient psychiatrist questioned Ms A about the recent overdose and suicide threats; she stated that she never intended to carry out her threats but was just trying to get attention.
Although health care providers may not take the threat of suicide seriously in patients who have BPD, these patients are often serious about suicide. Long-term studies indicate that compared with controls, patients with BPD have an 8% to 10% increased risk of completed suicide, which is comparable to that of patients who have MDD and schizophrenia.2 Moreover, minor overdoses frequently represent ambivalent suicide intent, and episodes of non-suicidal self-injury are markers for suicide risk and predict future suicide attempts.3,4
Conscious “attention-seeking” behavior is rare, although both patients and health care providers may attempt to frame suicidal behavior that way. As with Ms A, patients may minimize the seriousness of their intent, stating it was just “attention-seeking,” or “I was just trying to sleep,” making it easy for health care providers to question the validity of their patients’ actions.
On the other hand, not every gesture or threat is an indication for a prolonged inpatient hospital stay. Patients may threaten suicide as a way of obtaining or extending hospital stays. A study by Gregory and Jindal5 of 100 consecutive inpatient admissions showed that factitious production of suicide ideation, gestures, and threats was common among women with BPD at the time of discharge. Suicide threats and behavior served as a means of justifying the seriousness of their condition to providers, and to themselves. Given this information, is the underlying message that we should take suicidal ideation and behavior seriously, but not too seriously? How can we understand suicide risk in BPD?
What is already known about suicide risk in patients with borderline personality disorder (BPD)?
? Patients with BPD are at significant risk for completed suicide; episodes of nonsuicidal self-injury predict future suicide attempts.What new information does this article provide?
? The article provides a model for understanding suicide risk and behavior in patients with BPD and how that affects clinician-patient interactions.What are the implications for psychiatrists?
? Minor overdoses or superficial cutting behaviors are not merely attention-seeking, even if the patient says they are. Are patients placing blame on themselves or on others for recent interpersonal difficulties? If you find yourself in conflict with the patient, realize that the patient likely has an internal conflict over the same issue. A good therapeutic alliance includes clear expectations and boundaries, helping patients build autonomous motivation, and helping patients verbalize experiences and emotions.
Understanding the causes of suicide in BPD
The affect, mood, and behavior of patients with BPD can suddenly switch and appear contradictory, causing bewilderment and frustration for their health care providers. Patients can appear very depressed and suicidal at one moment and appear angry and entitled the next. Indeed, affective instability is the feature of BPD most closely associated with attempted suicide.6
Many clinicians have found the states of being model of dynamic deconstructive psychotherapy helpful for understanding affective instability in BPD and how it increases suicide risk.7 According to this model, patients with BPD can be triggered to switch between different states of being, or pseudo-personalities. In a matter of days, hours, or even minutes, patients can alternately appear helpless and childlike (helpless victim state), angry and self-righteous (angry victim state), or depressed and suicidal (guilty perpetrator state). These states are not methods of manipulation, but rather represent different sets of polarized and poorly integrated attributions of self and others.
When in the angry victim state, patients see themselves as heroic victims. They accept no responsibility for failures and instead blame others for their difficulties. They can become angry, manipulative, or violent in this state, since they perceive their actions as totally justified. This state is a defense against feelings of shame or humiliation and is triggered by situations that provoke such feelings. For example, Ms A reacted with rage when the consultant questioned the seriousness of her condition and the legitimacy of her suicide attempt. Patients are at low risk for suicide while in this state because they see the source of their difficulties as outside of themselves.
On the other hand, when in the guilty perpetrator state, patients with BPD are at significantly increased risk for suicide, especially when there are other risk factors, such as poor social supports, co-occurring alcohol misuse, or poor physical health.3 When in the guilty perpetrator state, patients take on total responsibility for every bad thing that has ever happened to them. They see their lives as a series of failures and bad decisions; they feel ugly, worthless, and evil—a pest that deserves to be exterminated.
In the guilty perpetrator state, the patient preserves an idealized image of others by taking all the badness onto himself or herself. This state is usually triggered by perceived rejection, abandonment, or separation anxiety, but it can also be triggered by any situation that causes the patient to become ambivalent toward major attachment figures. For example, Ms A’s initial presentation of having had a “bad day” was triggered by her therapist’s vacation. Instead of being able to acknowledge anger toward her therapist for abandoning her, Ms A maintained a positive image of her therapist by devaluing herself instead. During that day, Ms A’s self-image was the unlovable and difficult patient who was beyond help and who deserved to be “abandoned.” Despite Ms A’s later protestations, her overdose most likely included some suicide intent, in addi-tion to self-directed anger.
The states of being and rapidity of switching can be exacerbated by circumstances that intensify attachment wishes and fears, such as abusive relationships, prolonged hospital stays, or poor patient-therapist boundaries (physical touching, multiple contacts per week, extended sessions, etc). Patients can regress and become moody and childlike under these conditions: they react strongly to minor provocations and alternate rapidly between different states of being; their risk of suicide varies as well. The childlike qualities and sudden fluctuations in states contribute to health care providers’ confusion and skepticism.
Making the diagnosis
The first step in managing suicide risk in patients with BPD is to correctly identify the disorder. After multiple encounters that end in feeling manipulated or duped, physicians often come to assign the diagnosis of BPD only to patients whom they dislike or view as attention-seeking. Despite the importance of this diagnosis, physicians do not usually screen for BPD because making an accurate diagnosis can be time-consuming; they often come to believe that they can magically sense whether or not BPD is present.
Underdiagnosis of BPD is common, as is a misdiagnosis of bipolar disorder.8 Some indicators for systematic diagnostic screening for BPD include meeting criteria for multiple Axis I conditions; taking 3 or more psychiatric medications; or having evidence of behavioral dyscontrol, such as an eating disorder, substance use disorder, or recurrent incidents of self-harm. Routine use of brief self-rating scales, such as the McLean Screening Instrument for Borderline Personality Disorder9 and the patient questionnaire portion of the Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II),10 can also greatly enhance diagnostic accuracy.
The conflict within health care providers over whether their patient’s suicidal behavior and threats are legitimate mirrors a similar conflict within patients with BPD over whether their illness is legitimate, or whether they are totally to blame for their problems, attention-seeking, and needing to get their act together. Patients can rapidly switch states as they take one side of the conflict or the other, switching blame from self to others. Assessing the patient’s current state of being, recent stressors, alcohol misuse, and support system informs the health care provider about immediate risk. The Table provides some management strategies to minimize risk of suicide.
Consultant to the emergency department
• Look for triggers of suicidal ideation or behavior, especially abuse, separation, or loss; are these time-limited or on-going? Ask yourself what has changed between the time of the overdose and the present to lower the risk of suicide? Consider hospitalization if there have been no changes.
• When eliciting the history, look to see whether the patient is placing blame for current difficulties onto self or onto others: the first is strongly suggestive of the guilty perpetrator state and higher suicide risk; the second is suggestive of the angry victim state and lower suicide risk.
• Treat the patient with care and respect; sarcastic comments or a dismissive attitude can increase the risk for suicide or for aggressive behavior.
• Ultimately, the consultant may face a dilemma: discharge may be perceived as abandonment, whereas admission may lead to regression; either action can potentially increase suicide risk.11 It is usually helpful to convey this dilemma to the patient—he or she is more likely to assume an adult, responsible role if included in the decision-making process.
• Hospital stays should be kept short to minimize regression, generally a few days to a week.
• The goals of inpatient stays are brief stabilization, preparation for outpatient treatment, and consultation with the outpatient therapist. Ask the patient about patient-therapist boundaries and the nature of the relationships outside of therapy, especially issues of abuse, rejection, loss, and separation. Use motivational interviewing to build autonomous motivation for inpatient and outpatient treatment; a family meeting can help clarify possible precipitating factors for the admission.
• Excessive focus on co-occurring Axis I disorders and pharmacotherapy may worsen regression by fostering a passive sick role. Patients with Axis I disorders tend to respond poorly to usual treatment strategies when co-occurring borderline personality disorder (BPD) is present.12
• Avoid benzodiazepines to manage patient anxiety. Patients tend to like benzodiazepines and often describe them as the only medications that are helpful; however, benzodiazepines have been shown to worsen behaviors and mood dysregulation.13
• Patients provoke strong urges in health care providers to either adopt a nurturing role or be dismissive and scornful (the patient is just attention-seeking). Often, inpatient health care providers become split into opposing camps14; educate team members about this dynamic and about the causes of suicidal behaviors in this population.
• Manual-based treatments, such as dialectical behavior therapy,15 dynamic deconstructive psychotherapy,16 mentalization-based treatment,17 and transference-focused psychotherapy,18 are often much more effective than relying on clinical intuition and judgment in an eclectic, unstructured model.
• The most effective treatments for BPD strongly emphasize the importance of clear boundaries between patient and therapist and frequent case consultation with other therapists. Staying within the treatment frame can be extremely challenging with patients who have BPD, since they tend to evoke strong reactions in health care providers, both positive and negative.
• Encourage patients to take responsibility for maintaining their own safety and making a commitment to work toward recovery; this can be instituted as part of reviewing written treatment goals and expectations early in treatment.
• The single most effective technique to improve dissociation and core symptoms of BPD is to get patients to verbalize recent upsetting interpersonal experiences, create sequential narratives of these experiences, and label associated emotions.
Staying empathic and keeping the conflict within the patient instead of between the patient and health care provider, is a key to successful management. Other keys include maintaining clear expectations and boundaries, building autonomous motivation, and helping patients verbalize experiences and emotions.
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