The Borderline Personality Disorder and Suicide

If there are some cases where we ardently wish "to get it wrong" it is well this one.
We only wish one thing, to have the possibility to say "the author cry wolf" whereas there is not matter with...

But even if there is only one "bad luck" on a million so that the person we care suffer of a Borderline disorder and commit suicide, all the "quiet" circle of this person which have read this site or refuse to read this site would be entitled of damnation if by misfortune a such drama occur one day
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Series of articles, extracts raised on the subject. Again, all theses texts result from the American literature
The result is that the suicide rate ("successes") among patients suffering from a borderline disorder is 8 to 10% (1/10) whereas the suicide rate in the United States (all populations) is 0.011% (1/10000) (source NIMH) except miscalculation 1000 times more !

• The highest risk forBorderline patients, is between 19 years old and 34 years old
• 10 to 20% of people suffering from a mind disease have a borderline personality disorder
• The average age to commit suicide in BDP peoples is 32 years
• Article from National Mental Health Association on the warning signs of mental illness

Do people self-injure because they have BPD or because this is one way people cope with trauma, regardless of whether or not they have BPD?
A recent study showed that posttraumatic stress disorder, substance abuse and intermittent explosive disorder were significantly related to self-mutiliative behavior, regardless of whether or not the subjects had been diagnosed with BPD or antisocial personality disorder.  Also, high levels of dissociation were related to self-mutilation, after other factors, such as self-mutilation and BPD were controlled for (Zlotnick, 1999).

Is it nothing to worry about when a person almost completes suicide and stops before the completing the act?
A 1998 study discovered that the answer is "no."  Over half of the 135 subjects, who had been admitted to a hospital after an actual suicide attempt reported making at least 1 aborted suicide attempt previously.  Also, previous aborted suicide attempts were reported more often in subjects with a diagnosis of borderline personality disorder than in subjects with other diagnoses. Subjects who had made an aborted suicide attempt were nearly twice as likely to have made an actual suicide attempt as subjects with no aborted attempts (Barber, 1998)

What is the relationship between suicide and BPD?
A 1997 study closely examined the relationship between suicide and BPD and found that impulsivity was the only characteristic of borderline personality disorder (excluding the self-destructive criterion) that was associated with a higher number of previous suicide attempts after control for lifetime diagnoses of depression and substance abuse. History of childhood abuse correlated significantly with number of lifetime suicide attempts (Brodsky, 1997).

Many professionals don't take seriously threats of suicide by those whom have been diagnosed with Borderline Personality Disorder.  Perhaps they should review (Duberstein, 1997) which showed that  approximately 30-40% of suicides are committed by individuals with personality disorders, and (Bronisch, 1996) which showed that at least a third of completed suicides were made by those with personality disorders.

      A study done of 347 psychiatric patients at New York State Psychiatric Institute looked for reliable and generalizable predictors of suicidal behavior that would cross diagnostic boundaries.  What they found was that although certain diagnoses may cause stress, unless there was also a "diathesis" such as tendencies toward high suicidal ideation and impulsivity, a suicide attempt was not predictable based on diagnosis alone.  Since impulsive behavior is a strong facet of Borderline Personality Disorder, this information may help to explain why such a high percentage of completed suicides are by those with BPD (Mann, 1999).

Barber, Mary E.; Marzuk, Peter M.; Leon, Andrew C.; Portera, Laura.  (1998). Aborted suicide attempts: A new classification of suicidal behavior. American Journal of Psychiatry, 155(3) 385-389
Brodsky, Beth S.; Malone, Kevin M.; Ellis, Steven P.; Dulit, Rebecca A.; Mann, J. John. (1997).  Characteristics of borderline personality disorder associated with suicidal behavior. American Journal of Psychiatry, 154(12) 1715-1719
Bronisch, Thomas (1996).  The typology of personality disorders--Diagnostic problems and their relevance for suicidal behavior. Crisis, 17(2) 55-58
Duberstein, Paul R.; Conwell, Yeates.  (1997).  Personality disorders and completed suicide: A methodological and conceptual review.  Clinical Psychology: Science & Practice, 4(4) 359-376.
Kemperman, Ingrid; Russ, Mark J.; Clark, W. Crawford; Kakuma, Tatsuyuki; Zanine, Elizabeth; Harrison, Katherine (1997).  Pain assessment in self-injurious patients with borderline personality disorder using signal detection theory. Psychiatry Research, 70(3) 175-183
Mann, J. John; Waternaux, Christine; Haas, Gretchen L.; Malone, Kevin M. (1999). Toward a clinical model of suicidal behavior in psychiatric patients. American Journal of Psychiatry, 156(2) 181-189.
Zlotnick, Caron; Mattia, Jill I.; Zimmerman, Mark (1999).  Clinical correlates of self-mutilation in a sample of general psychiatric patients. Journal of Nervous & Mental Disease, 187(5) 296-301

PART A:
TREATMENT RECOMMENDATIONS FOR PATIENTS WITH BORDERLINE PERSONALITY DISORDER

IV. RISK MANAGEMENT ISSUES

A. GENERAL CONSIDERATIONS 
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B. SUICIDE 
Suicidal threats, gestures, and attempts are very common among patients with borderline personality disorder, and 8%–10% commit suicide. Managing suicide risk therefore poses important clinical and medicolegal challenges for clinicians.
However, it can be difficult to address suicide risk in these patients for a number of reasons.

• Monitor patients carefully for suicide risk and document this assessment; be aware that feelings of rejection, fears of abandonment, or a change in the treatment may precipitate suicidal ideation or attempts.
• Take suicide threats seriously and address them with the patient. Taking action (e.g., hospitalization) in an attempt to protect the patient from serious self-harm is indicated for acute suicide risk.
• Chronic suicidality without acute risk needs to be addressed in therapy (e.g., focusing on the interpersonal context of the suicidal feelings and addressing the need for the patient to take responsibility for his or her actions). If a patient with chronic suicidality becomes acutely suicidal, the clinician should take action in an attempt to prevent suicide.
• Actively treat comorbid axis I disorders, with particular attention to those that may contribute to or increase the risk of suicide (e.g., major depression, bipolar disorder, alcohol or drug abuse/dependence).
• If acute suicidality is present and not responding to the therapeutic approaches being used, consultation with a colleague should be considered.
• Consider involving the family (if otherwise clinically appropriate and with adequate attention to confidentiality issues) when patients are chronically suicidal. For acute suicidality, involve the family or a significant other if their involvement will potentially protect the patient from harm.

A promise to keep oneself safe (e.g., a "suicide contract") should not be used as a substitute for a careful and thorough clinical evaluation of the patient’s suicidality with accompanying documentation. However, some experienced clinicians carefully attend to and intentionally utilize the negotiation of the therapeutic alliance, including discussion of the patient’s responsibility to keep himself or herself safe, as a way to monitor and minimize the risk of suicide.

D. BOUNDRY VIOLATIONS 
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