Personality disorders: Self-harm and suicide
Managing patients who are chronically suicidal
Patients with borderline personality disorder (BPD) may attempt to harm themselves at some point in their lives. About 75 per cent will make a suicide attempt at some point and nine per cent will complete suicide (Frances, 2005).
Most primary care providers know how to assess and respond to acute suicidal risk, but a particular challenge with patients who have BPD is that they are often chronically suicidal. The chronically suicidal patient may not be an acute risk. Primary care providers need a practical means of responding clinically to these patients and discharging medico-legal liability to ensure safety.
Clinicians must convey to chronically suicidal patients that thay cannot take responsibility for these patients' lives. They must also help patients to understand that trying to harm themselves to see what the clinician and others will do is not an approrpriate way to determine whether these people care about them.
Clinicians should explain that self-harm behaviour means that the treatment is not working and may need to be reviewed.
Ongoing assessment and documentation
Because patients with a personality disorder may harm themselves when they are overwhelmed, assessing and documenting risk is crucial. Primary care providers should document self-harm assessment for all patients on all visits to manage and respond to this issue and to demonstrate for medico-legal reasons that they have addressed risk.
Use the mnemonic no SHIIT to document that the patient currently does not demonstrate:
ideation (I) or
For chronically suicidal patients, it may be necessary to have a protocol for a continuum of assessment and documentation. This protocol includes:
- indicating that the patient is not actively suicidal at this time but remains a chronic risk dependent on future substance use, disappointment or stress
- reviewing and documenting what patients will do if they become actively suicidal (e.g., call a family member or crisis line, go to the nearest emergency room)
- discussing the treatment with a colleague to make sure there is no medication or therapy approach that needs to be modified, as well as to note that the clinician has had this consultation
- noting that the colleague has agreed with the treatment, which is important in medico-legal risk management
Borderline personality disorder: recognition and management (NICE guideline CG78, 2009)
Antisocial personality disorder: prevention and management (NICE guideline CG77], 2008)
Clinical Practice Guideline for the Management of Borderline Personality Disorder (National Health and Medical Research Council, 2012)
Treatment guidelines for personality disorders (Project Air, 2015)