Clinical management for hospital-treated deliberate self-poisoning: comparisons between patients with major depression and borderline personality disorder

An Emic Perspective on the Dynamics of Non-Fatal Suicidal Behaviour in a Sample of South African Indian Women

We aimed to obtain an emic perspective on the dynamics of non-fatal suicidal behaviour in a high risk population group in South African, viz. adolescent females of Indian origin. Interviews were conducted with 10 respondents admitted to a state hospital in the greater Durban area, following their intentional overdose of prescription medication. Interviews were tape recorded, transcribed, and thematically analysed in an attempt to identify influences on suicidal behaviour. Intrapersonal influences on suicidal behaviour included poor communication and problem-solving skills. Interpersonal influences included family conflict, rigid and inflexible parental attitudes, a family history of attempted or completed suicide and high parental expectations. Socio-cultural influences related largely to conflicting social roles and values in the context of contemporary acculturation pressures. The study findings are discussed in terms of their implications for prevention and future research.

The girl who swallows knives: uncontrollable deliberate self-harm in a teenage girl with borderline personality disorder

The authors describe the case of a now 19-year-old girl who after a traumatic childhood, began to deliberately self-harm at the age of 13, often by cutting her forearms. More recently, however, swallowing inanimate objects has been her method of choice. At the time of writing, she has had over 150 accident and emergency department (A&E) attendances, over 10 gastroscopies and a laparotomy. Knives, razors and six-inch sewing pins have all been removed from her gastrointestinal tract. So far, psychiatrists have been unable to stop her and her risk of accidental death rises every time she deliberately self-harms. The authors include the patient's personal views on her illness and discuss borderline personality disorder as a condition.

Distinguishing suicidal from non-suicidal deliberate self-harm events in women with Borderline Personality Disorder

OBJECTIVE

Deliberate self-harm (DSH) is common in Borderline Personality Disorder, may be due to a variety of reasons, and is associated with different degrees of suicidal intent. Understanding the reasons for episodes of DSH in this population may be helpful in developing interventions to reduce the rate of DSH or to assist in the clinical judgement of suicidal intention after DSH has occurred.

METHODS

The Parasuicide History Interview, version 2 (PHI-2) was used to determine the reasons for DSH events in 70 Australian women diagnosed with Borderline Personality Disorder. Factor analysis of the responses identified four empirically derived component factors. Multivariate models were developed to identify the independent predictors of suicidal deliberate self-harm (S-DSH) versus non-suicidal deliberate self-harm (NS-DSH) events.

RESULTS

Participants and raters showed strong agreement in classifying S-DSH and NS-DSH events. Methods used that involved self-poisoning, jumping or stabbing showed increased risk for S-DSH, adjusted odds ratio 12.07 (95% CI 2.17, 67.29), compared to the referent group, external damage to skin with no rescue contact being sought. Although no grouping of reasons were independently significant, the lower the effectiveness of the DSH event to resolve the reasons for the event, the higher the risk of it having been a S-DSH event.

CONCLUSION

In clinical situations, any Borderline Personality Disorder patient seeking help or medical attention, using any method other than superficial external injury to skin, or reporting a failure to effectively resolve the reasons for the DSH event, should be considered as likely to have had a S-DSH event (greater suicidal intention). However, specific reasons for the DSH event, or individual subject characteristics, did not meaningfully distinguish S-DSH from NS-DSH events.

Management of complex and severe personality disorders in community mental health services

PURPOSE OF REVIEW

To describe the prevalence and specific management of severe and complex personality disorders in community mental health services and similar settings.

RECENT FINDINGS

Conflicting reports exist in the literature but the consensus of evidence suggests that more complex personality disorder (more so than simple personality disorder) impairs response to treatment of most psychiatric disorders and complicates their management. Poor adherence to treatment may be one of the mechanisms underlying this.

SUMMARY

Increasing evidence now suggests that more complex and severe personality disorders have a negative impact on the outcome of most psychiatric disorders. Some indications, however, are there to show that pharmacological treatments may not handicap the outcome of pharmacological treatment as much as other types of intervention and may be selectively chosen in this group. Severe personality disorder needs to be identified early in community services as by anticipating and adjusting to its effects it is likely to improve treatment plans and prognosis.

Suicide and deliberate self-harm in personality disorders

PURPOSE OF REVIEW

This article reviews literature published over the period January 2004-May 2005 on suicidal behaviour and self-harm in personality disorders.

RECENT FINDINGS

Studies have confirmed that personality disorders and their co-morbidity with other psychiatric conditions are risk factors for both fatal and nonfatal suicidal behaviours, and self-mutilation. Negative life events, childhood sexual abuse, difficulties in social functioning, deficits in future-directed thinking and time perception, as well as familial and neurocognitive factors may be related to increased suicide risk in individuals with borderline and other personality disorders. Findings seem to confirm that suicidality and self-injurious behaviour are efficient DSM-IV diagnostic criteria for borderline personality disorder. Out of several psychosocial and pharmacological interventions for treating suicidality in personality disorders, only one randomized, controlled study has recently been published. Medico-legal concerns related to the clinical management of chronically suicidal patients, including hospitalization and alternative treatment approaches, are also discussed.

SUMMARY

Although recent studies have contributed to the theoretical knowledge and clinical practice, there are unsettled questions that should be addressed in the future. More randomized, controlled trials evaluating the efficacy of interventions in suicidal individuals with personality disorders should be conducted. As the majority of studies conducted to date have concentrated on borderline personality disorder and antisocial personality disorder, the prevalence and risk factors for suicidal behaviours and self-mutilation in other personality disorders require further clarification. The introduction of unified nomenclature related to suicidal behaviours and self-mutilation would facilitate comparability of results across studies.