Part V - Treatment
Assessment and Emergency Management of Suicidality in Personality Disorders

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This article examines the association between suicidal behavior and personality disorders. It updates the review of epidemiological evidence for the association between suicidal behavior and suicide in individuals who have a personality disorder diagnosis, particularly in borderline personality disorder (BPD). The second part of the article presents new empirical evidence that characterizes suicidal behavior in patients who have BPD, specifically examining patient characteristics that differentiate patients who have BPD with a history of high versus low lethality suicide attempts. Finally, the article discusses the approach to a patient who has BPD and presents to the emergency department because of an increased risk of suicide.

Section snippets

Cluster B

Although significant epidemiological evidence exists to link personality disorders with suicidal behavior, most of this research concentrates on the Cluster B personality disorders. More limited research exists on Clusters A and C, and the evidence is reviewed according to respective clusters rather than individual personality disorders. We begin by reviewing the rates of personality disorders in subjects who have died by suicide or made suicide attempts. Then we present the rates of suicide

Characteristics of suicidal behavior in patients who have borderline personality disorder: empirical evidence

In working with patients who have BPD, clinicians have the unwieldy challenge of differentiating patients at high risk for suicide versus patients not at high risk. In this section, we use data from a randomized controlled clinical trial of 180 participants who had BPD and recurrent suicidal behavior and present the features of suicidal behavior that typify a sample of patients who have BPD. We also partially replicate an earlier investigation by Soloff and colleagues [29] to define predictors

Method

Eligible participants met the following inclusion criteria: BPD diagnosis by International Personality Disorder Examination (IPDE) [30], at least two parasuicides within the past 5 years, at least one parasuicide in last 3 months, more than 17 years of age, and not meeting the exclusion criteria; psychotic disorder, bipolar I disorder, current active substance dependence, organic brain syndrome or mental retardation, and chronic or serious physical health problem.

Based on the rating of medical

Results

The 180 participants were typical of most study samples of outpatients who have BPD. They were mainly women (86% female), average age 30 years (SD = 9.7), unmarried (only 15% married or in a relationship), with at least high school education (only 12% had less than grade 12), and most were unemployed (66% were currently unemployed). Based on our definition of high versus low lethality, 89 (49.4%) participants were considered to have a lifetime history of high lethality attempts, and 91 (50.6%)

Discussion

The current findings partially replicate the findings of Soloff and colleagues [29]. In the current sample, variables related to more extensive treatment histories (more exposure to medications and hospitalization), more evidence of psychosocial dysfunction, and evidence for greater suicide intent are convergent with Soloff and colleagues' findings. Soloff and colleagues [29] found more extensive treatment histories; lower SES and greater intent to die remained in the final model, explaining

Management of suicidality in the emergency department

In the first two sections of this article, we established the strong epidemiologic link between suicide, suicidal behavior, and BPD and the need for clinicians to differentiate between patients at high and low risk of suicide. Based on this evidence and our clinical experience, we turn our attention to the clinical management of suicidality in patients who have BPD who present to the emergency department. The American Psychiatric Association practice guidelines for the assessment and treatment

Summary

Several studies have illustrated a link between personality disorders, suicidal behavior, and suicide. The research is most robust in the field of BPD. BPD is a common and challenging diagnosis characterized by chronic suicidality, and we have attempted to differentiate between patients at risk for high versus low lethality suicide attempts. Although assessing and managing suicidality in patients who have BPD can be frustrating for even the most experienced clinicians, it is possible to

Acknowledgments

The authors wish to thank Shelley McMain for her invaluable feedback on the article.

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