Text adapted from: "The adult patient with a personality disorder," in Psychiatry in primary care by Michael Rosenbluth, Matthew Boyle & Lucille Schiffman (CAMH, 2019).
Self-harm and suicide
Self-harm is common among people with BPD. About 75 per cent make a suicide attempt at some point in their lives, and nine per cent complete suicide (Frances, 2005). Most primary care practitioners know how to assess and respond to acute suicide risk (see Suicide Risk). A particular challenge is that many patients are chronically suicidal, although they may not be at acute risk. To ensure the patient’s safety and to discharge medical liability, you need a practical approach for responding to these patients.
Make it clear to patients who are chronically suicidal that you cannot take responsibility for their lives. Explaining this may deter patients from self- harming to see what you will do, and ultimately to test whether you (or anyone else) cares about them. It is also helpful to explain that self-harm behaviour means the treatment is not working and the therapy may need to be reviewed.
Ongoing assessment and documentation of suicide risk
People with personality disorders may harm themselves when they are overwhelmed, so it is important to assess and document suicide risk. Assessing self-harm and documenting the assessment in all patients on all visits helps you to manage and respond to risks, and addresses medico-legal concerns. Documentation of each visit should include indicating that the patient currently does not demonstrate any self-harm, ideation or intent.
For patients who are chronically suicidal, you may need a protocol for a continuum of assessment and documentation. The continuum involves the following steps:
- indicating that the patient is not actively suicidal at this time but remains a chronic risk, depending 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 noting that you have had this consultation
- noting that the colleague has agreed with the treatment—this is important for medico-legal risk management.