How to manage chronic suicidality in Borderline Personality Disorder (BPD)?

Managing Chronic Suicidality in Borderline Personality Disorder

Dialectical Behavior Therapy (DBT) is the first-line treatment for managing chronic suicidality in patients with Borderline Personality Disorder, as it significantly reduces both suicidal and non-suicidal self-directed violence. 1

Evidence-Based Treatment Approach

Psychotherapeutic Interventions

1. Dialectical Behavior Therapy (DBT)

   • Specifically developed for BPD patients with chronic suicidality
   • Combines CBT, skills training, and mindfulness techniques
   • Focuses on developing skills in:
     • Emotion regulation
     • Interpersonal effectiveness
     • Distress tolerance
   • Multiple systematic reviews demonstrate DBT reduces both suicidal ideation and self-directed violence in BPD patients 1
   • More effective than client-oriented therapy in reducing post-treatment suicidal ideation and repetition of self-directed violence 1

2. Cognitive Behavioral Therapy (CBT)

   • Reduces suicidal ideation, behavior, and hopelessness
   • Typically involves fewer than 12 sessions
   • Systematic reviews show CBT cuts risk of post-treatment suicide attempts by half compared to treatment as usual 1
   • Particularly effective for patients with recent suicide attempts (within past 6 months) 2

3. Problem-Solving Therapy

   • Type of CBT specifically aimed at improving coping with stressful life experiences
   • Particularly effective for addressing hopelessness 1, 2
   • Teaches active problem-solving skills to manage suicidal crises

Crisis Management Components

1. Crisis Response Planning

   • Collaborative approach between patient and clinician
   • Key components include:
     • Semi-structured interview about suicidal ideation and history
     • Discussion about recent stressors using supportive listening
     • Identification of clear signs of crisis (behavioral, cognitive, affective, physical)
     • Development of self-management skills for distress
     • Identification of social support networks
     • Review of crisis resources and emergency contacts
   • Significantly more effective than treatment as usual in reducing suicide attempts 1

2. Safety Planning

   • Create a written safety plan including:
     • Warning signs and triggers for suicidal thoughts
     • Coping strategies and healthy distracting activities
     • Social supports and professional resources
     • Emergency contacts
     • Means restriction planning
   • Associated with a 43% reduction in suicidal behavior 2

3. Means Restriction Counseling

   • Critical component of management
   • Focus on securing potential means of self-harm (knives, medications, firearms)
   • Particularly important as many suicide attempts in BPD are impulsive 2

Pharmacological Considerations

1. Limited Role of Medications for Core BPD Symptoms

   • No evidence that any psychoactive medication consistently improves core symptoms of BPD 3, 4
   • Medications should be targeted at specific comorbid conditions

2. For Comorbid Conditions

   • Mood Disorders: Consider SSRIs (escitalopram, sertraline, fluoxetine) for comorbid depression 4
   • Bipolar Disorder: Lithium may reduce suicide risk in patients with comorbid bipolar disorder 1, 2
   • Acute Crisis: Low-potency antipsychotics (e.g., quetiapine) or sedative antihistamines (e.g., promethazine) preferred over benzodiazepines 4

3. Cautions

   • Avoid benzodiazepines when possible as they may increase disinhibition and suicide risk 2
   • SSRIs should be used with caution due to risk of triggering mania if bipolar disorder is present 2

Follow-up and Monitoring

1. Regular Follow-up

   • Schedule consistent appointments
   • Close clinical supervision especially during:
     • First year after hospital discharge
     • Medication initiation or dose changes
     • Transitions between treatment settings 2

2. Caring Communications

   • Periodic postcards, letters, or text messages for 12 months following hospitalization
   • Can reduce suicide attempts and ideation 2

3. Family Education and Involvement

   • Counsel families about suicide risk and treatment
   • Involve them in means restriction planning
   • Ensure they know warning signs and how to respond 2

Common Pitfalls to Avoid

1. Relying on no-suicide contracts - No empirical evidence supporting efficacy 2

2. Implicit coercion - Avoid telling patients they won't be discharged until they state they are not suicidal 2

3. Underestimating access to lethal means - Patients often have greater access than providers or families realize 2

4. Inadequate monitoring after discharge - First year after hospitalization carries significantly elevated suicide risk 2

5. Overlooking comorbid substance use disorders - Significantly increases suicide risk and complicates treatment 2, 5

6. Treating self-mutilation as less serious - Self-mutilation is associated with approximately twice the rate of completed suicide 5

Special Considerations

1. High Prevalence of Comorbidity

   • Most people with BPD have coexisting mental disorders:
     • Mood disorders (83%)
     • Anxiety disorders (85%)
     • Substance use disorders (78%) 4
   • These comorbidities can complicate treatment and increase suicide risk

2. Chronic Nature of Suicidality

   • Understand that suicidal ideation in BPD is often chronic rather than acute
   • Focus on managing rather than eliminating suicidal thoughts
   • Distinguish between chronic suicidal thoughts and acute suicide risk

3. Behavioral Activation

   • May be useful as an adjunctive approach
   • Helps reduce depression and increase engagement in positive activities 6
   • Can be integrated with DBT approaches