Managing Suicide Risk in Borderline Personality Disorder
Distinguishing Real Risk From Attention Seeking
Although health care providers may not take the threat of suicide seriously in patients who have BPD, these patients are often serious about suicide. Long-term studies indicate that compared with controls, patients with BPD have an 8% to 10% increased risk of completed suicide, which is comparable to that of patients who have MDD and schizophrenia.2 Moreover, minor overdoses frequently represent ambivalent suicide intent, and episodes of non-suicidal self-injury are markers for suicide risk and predict future suicide attempts.3,4
Conscious “attention-seeking” behavior is rare, although both patients and health care providers may attempt to frame suicidal behavior that way. As with Ms A, patients may minimize the seriousness of their intent, stating it was just “attention-seeking,” or “I was just trying to sleep,” making it easy for health care providers to question the validity of their patients’ actions.
On the other hand, not every gesture or threat is an indication for a prolonged inpatient hospital stay. Patients may threaten suicide as a way of obtaining or extending hospital stays. A study by Gregory and Jindal5 of 100 consecutive inpatient admissions showed that factitious production of suicide ideation, gestures, and threats was common among women with BPD at the time of discharge. Suicide threats and behavior served as a means of justifying the seriousness of their condition to providers, and to themselves. Given this information, is the underlying message that we should take suicidal ideation and behavior seriously, but not too seriously? How can we understand suicide risk in BPD?