Introduction to the Special Feature On Suicide and Borderline Personality Disorder

Abstract

Suicide attempts and threats are a defining feature of borderline personality disorder (BPD). The chronic suicidality that characterizes BPD can arouse strong reactions in clinicians. Many clinicians are alarmed, some will be fascinated, whereas others may prefer to avoid these patients. In this special section, the Journal of Personality Disorders asked four authors to review what the literature tells us about managing suicidality in BPD. Reflecting the fact that research is far from definitive, the experts do not quite agree, particularly about the value of hospital admission. Black, Blum, Pfohl, and Hale (2004) suggest that attempts and completions can be prevented by understanding risk factors. Thus, Black et al. support the conclusions of the American Psychiatric Association Practice Guideline (Oldham et al., 2001), which favors hospitalization (including the use of locked wards) to prevent patients from committing suicide. Conversely, Sansone (2004) is very doubtful about the utility of hospitalization, which, as he points out, carries its own risks. Reviewing the literature on the differences between acute and chronic suicidality, Sansone concludes that the clinical strategy for BPD must be different from that for depression, and that the mainstay of management, even when patients threaten suicide, is outpatient therapy. My own article (Paris, 2004) takes a very similar view. Like Sansone, I question the application of guidelines developed for acutely suicidal depressed patients without personality disorders to patients with BPD; I suggest that the management of chronically suicidal patients has to take a very different approach. I also emphasize the complications associated with repetitive hospitalization. No study has ever shown that hospitalizing patients with BPD prevents suicide. In my experience, many of my colleagues understand this point but they admit patients anyway, out of fear of “medico-legal” problems. This issue is addressed by Gutheil (2004), who dispels some of the fear associated the possibility of litigation, and who shows how clinicians managing patients with BPD can handle the risk. Journal of Personality Disorders, 18(3), 213-214, 2004 © 2004 The Guilford Press