Treating Chronic Suicidality

Suicidal behavior describes not only death caused by suicide but also intentional, nonfatal, self-injurious acts committed with or without the intent to cause death. Less severe suicidal attempts are particularly characteristic of persons with borderline personality disorder (BPD).

As defined in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV-TR),¹ persons with BPD exhibit a pervasive pattern of instability in interpersonal relationships, self-image, and affects. These difficulties typically begin by early adulthood and persist. About 80% of persons with BPD are women. Although the term “borderline” suggests that these persons are on the edge of psychosis (and some may show transient, stress-related paranoid thinking or severe dissociative symptoms), psychosis is not the core problem. Rather, the core symptoms are affective instability, impulsivity, and disturbed relationships.

In clinical populations, the rate of suicide completion by persons with BPD is estimated at 8% to 10%, although a far greater number (60% to 70%) make unsuccessful suicide attempts. Risk factors for suicidal behavior include prior suicide attempts, comorbid mood disorder, feelings of hopelessness, family history of completed suicide or suicidal behavior, comorbid substance abuse, history of sexual abuse, and high levels of impulsivity and/or antisocial traits.2 APA

Treatment Guidelines
In 2001, the American Psychiatric Association (APA) issued its Practice Guideline for the Treatment of Patients With Borderline Personality Disorder,³ which recommended psychotherapy as the primary, or core, evidence-based treatment for BPD, whether or not suicidality was prominent in a given patient.

In 2005, the APA issued a Guideline Watch,⁴ updating its 2001 recommendations. It continued to support the original guideline that psychotherapy represents the primary, or core, treatment, but it also states that adjunctive, symptom-targeted pharmacotherapy can be helpful. The updated recommendation cites some studies documenting that the newer-generation neuroleptics, generally in low doses, are useful in treating cognitive-perceptual symptoms, and that SSRIs may be helpful for stabilizing impulsive aggression or affective dysregulation.

Psychotherapy
A number of promising new psychotherapies for BPD are available. These include interpersonal therapy,⁵ systems training for emotional predictability and problem solving (STEPPS),⁶ a cognitive-behavioral approach done in a time-limited group format, and others. However, the psychotherapy that has so far shown the best results is dialectical behavioral therapy (DBT), especially for the difficult-to-treat chronic suicidality component of BPD.

DBT is a form of psychotherapy within the framework of cognitive-behavioral therapy that has been developed by Marsha M. Linehan, PhD, a clinical psychologist, specifically to treat persons with BPD who have a history of suicidal behavior. Factors contributing to the relative prominence of DBT include the availability of a treatment manual and workbook. In addition, findings of numerous randomized controlled trials have shown DBT to be more effective than usual treatment.⁷

Individual treatment focuses primarily on motivational issues, including the motivation to live and to continue treatment. Group therapy sessions teach self-regulation and change skills, and how to move toward self-acceptance and acceptance of others. There is a simultaneous focus of patient functioning on acceptance and validation strategies as well as change strategies to achieve a synthetic (dialectical) balance.⁸

The usual procedure is for persons to be offered a treatment contract for 1 year. Treatment consists of 1 individual session (1 hour) and 1 group session (2 hours of skills training) per week. Telephone coaching is available from the individual session therapist between sessions, 7 days a week.

In the first year of treatment, the initial aim is to stop the life-threatening and self-harming behaviors (target 1), chronic lateness and disruptive behaviors (target 2), and crisis-generating behaviors, such as substance misuse (target 3). Weekly group sessions teach new skills in mindfulness, emotional regulation, interpersonal effectiveness, and distress tolerance. The individual therapist also assumes the role of care coordinator, arranging for medication reviews and ongoing risk assessment, and liaison with primary care and other services.⁹

Particularly persuasive to me were the results of a 2-year randomized controlled trial and follow-up of DBT versus therapy by other experts in suicidal behaviors and BPD.¹⁰ The study population was 101 clinically referred women with recent suicidal and self-injurious behavior meeting DSM-IV criteria for BPD, divided into 2 carefully matched cohorts. DBT was associated with better outcomes in the intent-to-treat analysis than community treatment by experts using other forms of psychotherapy during the 1 year of active treatment and 1 year of follow-up. Participants who received DBT were half as likely to make a suicide attempt, required fewer hospitalizations for suicide ideation, and had lower medical risk for all suicide attempts and self-injurious acts combined. Participants who received DBT also were less likely to drop out of treatment, had fewer psychiatric hospitalizations, and had fewer psychiatric emergency department visits.

Conclusion
The past 10 to 15 years have seen dramatic progress in the treatment of persons with BPD. DBT, in particular, offers hope for dealing with a condition that used to depress not only persons with BPD but also those trying to help them.

References:

References
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Arlington, VA: American Psychiatric Publishing, Inc; 2000:706-710.
2. Oldham J. Borderline personality disorder and suicidality. Am J Psychiatry. 2006;163:20-26.
3. American Psychiatric Association. Practice Guideline for the Treatment of Patients With Borderline Personality Disorder. Arlington, VA: American Psychiatric Association; October 2001. http://www.psychiatryonline.com/ pracGuide/ pracGuideChapToc_13.aspx. Accessed May 26, 2009.
4. Oldham JM. Guideline Watch: Practice Guideline for the Treatment of Patients With Borderline Personality Disorder. Arlington, VA: American Psychiatric Association; 2005. http://www.psychiatryonline.com/content.aspx?aID=148718. Accessed May 26, 2009.
5. Markowitz JC. Interpersonal therapy. In: Oldham JM, Skodol AE, Bender DS, eds. Textbook of Personality Disorders. Arlington, VA: American Psychiatric Publishing Inc; 2005:321-334.
6. Blum N, Pfohl B, John DS, et al. STEPPS: a cognitive-behavioral systems-based group treatment for outpatients with borderline personality disorder-a preliminary report. Compr Psychiatry. 2002;43:301-310.
7. Blennerhassett RC, O’Raghallaigh JW. Dialectical behavior therapy in the treatment of borderline personality disorder. Br J Psychiatry. 2005;186:278-280.
8. Verheul R, Van Den Bosch LM, Koeter MW, et al. Dialectic behavior therapy for women with borderline personality disorder: 12-month, randomized clinical trial in The Netherlands. Br J Psychiatry. 2003;182:135-140.
9. Zinkler M, Gaglia A, Rajagopal Arokiadass SM, Farhy E. Dialectical behavior treatment: implementation and outcomes. Psychiatr Bull. 2007;31:249-252.
10. Linehan MM, Comtois KA, Murray AM, et al. Two-year randomized control trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder [published correction appears in Arch Gen Psychiatry. 2006;64:1401]. Arch Gen Psychiatry. 2006;63: 757-766.