Personality Disorders & Suicide: Causes, Treatment, Interventions and Resources

1. Personality Disorders & Suicide: Causes, Treatment, Interventions and Resources Anna Lieber, CMHC, NCC March 16, 2019 UMHCA Conference

2. The desire for an escape from suffering & pain is a universal human emotion

3. Personality Disorders DSM 5 Definition – PD’s impair an individual’s • Cognition (perception & interpretation of self, others, and events) • Affectivity (range, intensity & appropriateness of emotional response) • Interpersonal functioning • Impulse control • 9-10% of adults have been diagnosed with a PD • PD’s impact core beliefs and schemas

4. How PD differs from other behavioral health disorders (Axis I) • EGO-DYSTONIC = thoughts, impulses and behaviors that are distressing, unacceptable, or inconsistent with one’s self-concept -VS- • EGO-SYNTONIC = instincts or ideas that are acceptable to the self

5. PERSONALITY DISORDERS Cluster A Odd, Eccentric • Paranoid • Schizoid • Schizotypal Cluster B Dramatic, Erratic, Emotional • Antisocial • Borderline • Histrionic • Narcissistic Cluster C Anxious, Fearful • Avoidant • Dependent • Obsessive-Compulsive

6. Suicidality = the crisis of self • “Contemplating suicide is like no other feeling. This life force within you that has taken you from birth to this present critical moment is losing its potency. Despite the joys and wonders of this extraordinary gift of life, you are thinking that it’s not worth it. For whatever reason, life has become too difficult, too painful …. and extinguishing this life force becomes a real possibility.” • David Webb – Suicidologist – Victoria University (2002)

7. https://youtu.be/EOamGvnFWkM

8. Assessment of Suicide Risk: From Prediction to Prevention Pisani, A., Murrie, D., & Silverman, M. (2015). Reformulating Suicide Risk Formulation: From Prediction to Prevention. Acad Psychiatry .

9. Assessment of Suicide Risk • Phenomenology of Suicide = understanding as it is experienced by those who live it • Ambivalence is always present – lean into the inner conflict Suicide Risk is increased: • Within 1 week after discharge from a psychiatric admission or ED visit • First weeks after any medication changes • During significant life transitions (positive or negative)

10. Assessment of Suicide Risk • Crisis of Self “All my life I have felt a mismatch between the ‘in-here’ and the ‘out-there’, where my innermost sense of self clashed with how the world seemed to perceive me and, perhaps, the person I was trying to be. I felt I was living a lie, a fraud in fear of being exposed. Twice these fears were unleashed in their full force and overwhelmed me with how meaningless my life was. There was no way out of this pain. I could not bear being me. Suicide became increasingly the logical, most attractive and, ultimately only option.” https://thinkingaboutsuicide.org/phenomenology-of-suicidality/

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13. CLUSTER B: Antisocial, Borderline, Narcissistic, Histrionic • Malignant Alienation • Narcissistic – increased risk of suicide – especially when a significant ego-threatening trigger occurs • BPD – 70% have 1 or more suicide attempts & 10% die by suicide • Younger Age • Non-suicidal self-injurious behaviors • General negative temperament • Substance use • Shame • Co-morbid MH disorders (psychosis, bipolar, MDD, PTSD) Death by suicide rate for BPD is 50 x greater than the general population. Mood disorders (i.e. MDD, bipolar) is 25 x the general population

14. CLUSTER B: Antisocial, Borderline, Narcissistic, Histrionic CRISIS MANAGEMENT • Avoid Complements & small talk • Therapeutic Boundaries • Direct Questions • Assess Risk State • Understand their Phenomenology

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16. https://youtu.be/7FfjCA72xbM

17. Suicide Risk Assessment Techniques for Eliciting Suicide Ideation, Intent, Plans & Behavior: • Normalization • Shame Attenuation • Behavioral Incident • Gentle Assumption • Denial of the Specific (Adults only) • Symptom Amplification • Ask about other plans/behaviors • Safety Plan (not contracts) • Assess Reason for living = dig into the ambivalence and smallest of hope

18. Non-Suicidal Self-Injury (NSSI) • CDC Definition – Behavior that is self-directed and deliberately results in injury or the potential for injury to oneself. There is no evidence, implicit, or explicit of suicidal intent. • Possible motivations: • Punishment • Establishing emotional/cognitive congruence • Self-regulation • Possible addiction

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20. Crisis Management • Dilemma with suicide (and conflict): “The therapist’s goal is to prevent suicide and the client’s goal is to eliminate pain & suffering via suicidal behavior.” • Therapeutic Teams • Self-care • We will make mistakes It is only through our own practice of self-compassion that we will be able to express compassion for individuals with personality disorders

21. References & Resources • Ansell, E., Wright, A., Markowitz, J., Sanislow, C., Hopwood, C., Zanarini, M., . . . Grilo, C. (2015 April 6(2)). Personality disorder risk factors for suicide attempts over 10 years of follow-up. Personal Disord, 161-167. • Blasco-Fontecilla, H., Baca-Garcia, E., Dervic, K., Perez-Rodriguez, M., Saiz-Gonzalez, M., Saiz-Ruiz, J., . . . de Leon, J. (2009 119). Severity of personality disorders and suicide attempt. Acta Psychiatr Scand, 149-155. • Ghahramanlou-Holloway, M., Lee-Tauler, S., LaCroix, J., Kauten, R., Perera, K., Chen, R. W., & Soumoff, A. (2018 (82)). Dysfunctional personality disorder beliefs and lifetime suicide attempts among psychiatrically hospitalized military personnel. Comprehensive Psychiatry , 108-114. • Houston, M. (2017). Treating suicidal clients & self-harm behaviors. Eau Claire, WI. PESI, Inc. • Oldham, J. M. (January 2006). Borderline personality disorder and suicidality. AM J Psychiatry 163:1. • Pisani, A., Murrie, D., & Silverman, M. (2015). Reformulating Suicide Risk Formulation: From Prediction to Prevention. Acad Psychiatry . • Schneider, B., Schnabel, A., Wetterline, T., Bartusch, B., Weber, B., & Georgi, K. (2008). How do personality disorders modify suicide risk? Journal of Personality Disorders 22(3), 233-245. • Webb, D. (2002). The many languages of suicide. Suicide Prevention Australia Conference. Sydney, June 2002. • Weding, M., Silverman, M., Frankenburg, F., Bradford Reich, D., Fitzmaurice, G., & Zanarini, M. (2012 Vol. 42 ). Predictors of suicide attempts in patients with borderline personality disorder over 16 years of prospective follow-up. Psychological Medicine, 2395-2404. • Yen, S., Shea, T., Pagano, M., Sanislow, C., Grilo, C., McGlashan, T., Skodol, A., Bender, D., Zanarini, M. & Gunderson, J. (2003 Vol. 112) Axis I and axis II disorders as predictors of prospective suicide attempts: findings from the collaborative longitudinal personality disorders study. Journal of Abnormal Psychology. 375-381 • https://thinkingaboutsuicide.org/phenomenology-of-suicidality/ • www.beckinstitute.org • https://borderlinethefilm.com/projects/ • www.sprc.org • http://www.mentalhealthamerica.net/ • https://afsp.org • https://www.nimh.nih.gov/health/statistics/personality-disorders.shtml

22. Admissions: 801-264-6000 24/7 free crisis assessments & referrals Anna Lieber, CMHC, NCC/CCMHCDirector of Clinical Services801-264-60033802 South 700 East Salt Lake City, UT 84106Anna.lieber@uhsinc.com