1. Anna Lieber, CMHC, NCC March 16, 2019 UMHCA Conference
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
Provide examples of how PD’s impact core beliefs.

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
VIDEO: What it’s like to have passive suicidal thoughts

8. Assessment of Suicide Risk: From Prediction to Prevention
Despite numerous years of study and research we cannot predict suicide. We aren’t good at it. --- however, by anchoring that risk – especially with chronic suicidality we can make better more informed decisions collaboratively with our clients.
ANCHOR ---
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)
Ask – what is this or that kind of experience like? - what is it like to be suicidal. The phenomenology of suicide disappeared from research for many years with the development of complex screening tools – focusing on the observable clinical data – previous attempts, family members who died by suicide, hx of trauma.. Categorizing individuals into numbers of High Medium and Low Risk. - Now finally we are beginning in the last decade to seen a return to looking at the inner experience of individuals with chronic suicidality.

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.”

11. https://youtu.be/ARiIRt1gN4w
VIDEO: Marsha Linehan: Stigma & Suicidality

12. https://youtu.be/AtbcmDMIvB8
VIDEO: Valerie Porr: Stigma: When All Else Fails (and Treaters Often Do), Blame the Patient!

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

15. https://youtu.be/M0XeXZdxOBg
VIDEO: Borderline Personality Disorder: An Inner Monologue

16. https://youtu.be/7FfjCA72xbM
VIDEO: Valerie Porr discusses Shame

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

19. https://youtu.be/c9LIqvIuEw0
VIDEO: Marsha Linehan discusses - Risky Business: Treating Suicidal Patients

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,
Blasco-Fontecilla, H., Baca-Garcia, E., Dervic, K., Perez-Rodriguez, M., Saiz-Gonzalez, M., Saiz-Ruiz, J., de Leon, J. ( ). Severity of personality disorders and suicide attempt. Acta Psychiatr Scand,
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 ,
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),
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,
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

22. Admissions: /7 free crisis assessments & referrals Anna Lieber, CMHC, NCC/CCMHC Director of Clinical Services South 700 East Salt Lake City, UT