Risk Management and the Suicidal Patient

Abstract

In the management of the suicidal patient, fear of criticism or adverse findings by coroners’ courts can inappropriately influence a clinician's decision-making. The management particularly of the patient with borderline personality disorder, who deliberately self-harms or is suicidal, is made more challenging by the negative transference these patients may evoke.

Adherence to evidence-based practice – excluding comorbid or differential diagnoses, crisis management, judicious hospital admissions, targeted medication and appropriate outpatient therapies – as well as detailed contemporaneous documentation of the decision-making are the mainstays of risk management of the patient with borderline personality disorder. The management plan should be informed by cross-sectional risk assessments and serial risk-benefit analyses. After providing illness education, the scenario planning and crisis intervention plan should be agreed with the patient and the patient's family and supports. Maintaining continuing professional development and peer review will also best approximate the “peer professional opinion” which is mandated by the various Civil Liability Act provisions in all Australian jurisdictions.

Key words:

• borderline personality disorder
• risk management
• suicide

Notes

a. At [5].

b. At [108].

c. At [117].

d. In December 2015, the chairman of Lifeline Australia John Brogden (who, in August 2005, attempted suicide after he suddenly resigned as Leader of the NSW Opposition) called for the wider publication of regular national suicide statistics, like the national road toll, to increase awareness to help reduce suicide in Australia: John Brogden seeks national suicide toll as way to reduce deaths. Available from: URL:http://www.theaustralian.com.au/national-affairs/health/john-brogden-seeks-national-suicide-toll-as-way-to-reduce-deaths/news-story/8a6fa46f99fc17960cb6612826b9a5b7; see also Brogden J. Out of the shadows – my story. Available from: URL:https://www.outoftheshadows.org.au/Home/My-Story/John-Brogden

e. Between 2001 and 2010, the 996 suicide deaths registered across Australia where the deceased person was identified as being of Aboriginal or Torres Strait Islander origin represented approximately 5% of all suicide deaths in that period: Australian Bureau of Statistics, 2010. Aboriginal and Torres Strait Islander Suicide Deaths. Available from: URL:http://www.abs.gov.au/ausstats/[email protected]/Products/3309.0∼2010∼Chapter∼Aboriginal+and+Torres+Strait+Islander+suicide+deaths; see also Aboriginal girl's suicide prompts second inquest. Available from: URL:http://www.theaustralian.com.au/news/briefs-nation/aboriginal-girls-suicide-prompts-second-inquest/news-story/c6d32a46e0eb25b4829ad8181e38327e

f. A pervasive pattern of instability of interpersonal relationships, self-image and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

1. Frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.

2. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.

3. Identity disturbance: markedly and persistently unstable self-image or sense of self.

4. Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.

5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.

6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability or anxiety usually lasting a few hours and only rarely more than a few days).

7. Chronic feelings of emptiness.

8. Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).

9. Transient, stress-related paranoid ideation or severe dissociative symptoms.

g. Key recommendation number 31 (at [6]) in executive summary).

h. The Royal Australian and New Zealand College of Psychiatrists (RANZCP) has not updated the clinical practice guidelines for the management of adult deliberate self-harm since 2004: Australian and New Zealand clinical practice guidelines for the management of adult deliberate self-harm. Australian and New Zealand Journal of Psychiatry 2004;38:868–84.

i. Key recommendation number 11 (at [6] in executive summary).

j. For a discussion of Civil Liability Act provisions and “peer professional opinion”, see Scott R. Liability for health services for not involuntarily detaining and treating a mentally ill person – McKenna v Hunter & New England Local Health District; Simon v Hunter & New England Local Health District [2014] HCA 44. Psychiatry, Psychology and Law 2015;22(1):1–31.