Psychiatric Annals

CME Article 

Management of Suicidality with Borderline and Narcissistic Features

Brandon T. Unruh, MD

Abstract

General suicide risk assessment and management should include consideration of core borderline and narcissistic vulnerabilities of interpersonal hypersensitivity and self-esteem dysregulation. Understanding the oscillating phenomenology of these vulnerabilities using the basic personality disorder treatment approach of Good Psychiatric Management provides a coherent, practical method for assessing and managing suicide risk not only in patients with these personality disorders but more broadly in those with some traits of personality disorder but not meeting full diagnostic criteria. [Psychiatr Ann. 2020;50(4):139–145.]

Abstract

General suicide risk assessment and management should include consideration of core borderline and narcissistic vulnerabilities of interpersonal hypersensitivity and self-esteem dysregulation. Understanding the oscillating phenomenology of these vulnerabilities using the basic personality disorder treatment approach of Good Psychiatric Management provides a coherent, practical method for assessing and managing suicide risk not only in patients with these personality disorders but more broadly in those with some traits of personality disorder but not meeting full diagnostic criteria. [Psychiatr Ann. 2020;50(4):139–145.]

This article explains how the lens of personality functioning and treatments for borderline personality disorder (BPD) and narcissistic personality disorder (NPD) can facilitate a coherent and individualized approach to suicide risk assessment and management, even when criteria for personality disorder diagnosis do not fully apply. Clinicians typically begin by evaluating for the presence of key demographic and psychiatric risk factors identified in large-scale population studies. These include being male, having one or especially multiple mental disorders, being an adolescent or older adult, lower educational attainment, being unmarried, and being unemployed.1 This checklist approach is often combined with more psychologically attuned monitoring for the emergence of “transdiagnostic” mental state risk factors imminently heralding suicidal behavior. Most proposed pathways to suicide converge around escape from apparently intolerable affective experience.2–7

A more individualized approach focuses on how imminently suicidal affective states emerge in some people but not in others, from interactions between underlying psychological vulnerabilities and adverse life events. A further complication is that life events and developmental challenges often prompt suicide crisis in people not meeting criteria or being treated for any major psychiatric disorder.8 For example, only one-half of people who died by suicide during a 10-year study received a mental health diagnosis or treatment during the previous year.9 An estimated 10% to 37% of suicides occur in the absence of psychiatric disorders.10,11 These observations suggest that a more individualized and fine-grained phenomenological approach must be employed to understand how certain patterns of psychological vulnerabilities not necessarily meeting psychiatric diagnostic criteria interact with macroscopic clinical risk factors, adverse life events, and developmental challenges to produce imminently suicidal mental states. The lens of personality disorder phenomenology can help clinicians organize, differentiate, and treat psychological vulnerabilities commonly leading to suicide.

Personality Disorder Treatments Can Enhance Individualized Suicide Risk Assessment and Management

BPD and NPD are among the diagnoses most closely associated with completed suicide.12,13 Despite disagreement between various theories about the core psychopathology of BPD, at least five treatments targeting BPD have demonstrated reductions in suicidal behavior.14–17 Common principles and techniques of these treatments have been distilled into more broadly applicable treatment approaches offering greater focus on the role of specific contextual factors and life events influencing suicide risk for people not meeting criteria for personality disorder.16–18

Personality disorder suggests serious impairment in interpersonal relationships, intimacy, emotion regulation, behavioral control, identity, and self-direction. Clinical strategies effective for these core ingredients also help suicidal patients without a diagnosis of a personality disorder. This view fits studies on the latent structure of personality indicating that, just like the problem of suicide, basic units of personality dysfunction cut across rigid diagnostic categories.19 Optimizing interpersonal relationships, improving emotional processing and regulation, enhancing behavioral control, and promoting self-reflection to stabilize views of self and others are relevant in the treatment of any suicidal person. Thus, attunement to basic issues of personality functioning helps clinicians organize the treatment frame around relevant psychological processes.

Good Psychiatric Management as “Primary Care” for BPD

Five treatments for BPD are now empirically well established, each with efficacy for reducing suicidal behavior.17 Of these five, Good Psychiatric Management (GPM) for BPD was uniquely developed as a “primary care” intervention involving straightforward principles and techniques for managing BPD that can be realistically learned during training and flexibly implemented in a cost-effective manner across many practice settings.20–23 The efficacy of GPM for BPD was found to be equivalent in a large-scale trial against dialectical-behavior therapy (a more costly and resource-intensive specialist treatment) across a wide variety of outcome measures including suicidal and nonsuicidal self-injurious behavior.24,25

General Features of Suicidality in BPD

Recurrent suicidal acts, threats, and urges are nearly pathognomonic of BPD. Intentional and planful suicide attempts often co-occur with nonsuicidal self-harming acts. Self-destructive behavior in BPD is typically ambivalent, conflicted or unclear in intent, and not lethal. It is usually preceded or followed by reaching out for help and, therefore, associated with higher likelihood of rescue.

Suicide attempts in BPD are typically precipitated by interpersonal experiences of real or perceived rejection or loss of support.26–28 A core vulnerability mediating progression toward suicide in BPD is interpersonal hypersensitivity.29 Additional factors prospectively associated with eventual completed suicide include active comorbidities (major depression, substance use disorders, and posttraumatic stress disorder), demographic and historical features (completed suicide in a caretaker, adult sexual assault), and the presence of specific BPD symptoms (self-harm, affective instability, dissociation).30 Although active self-harm is associated with risk of eventual completed suicide, it is not clear whether it has a causal role; however, active self-harm associated with escalating levels of lethality may be a stronger signal of imminent risk.

GPM'S “Interpersonal Coherence” Phenomenology of Suicidality in BPD

As outlined in Table 1, suicide risk in BPD correlates with perceived level of interpersonal connectedness.20 Helpful interventions can be organized in GPM according to a schematic understanding of BPD's “interpersonal coherence,” comprising four different levels of connectedness. People with BPD are idealizing and collaborative when feeling connected and supported by a dependable relationship. In the face of perceived or actual rejection or abandonment, they can become anxious and feel threatened, make suicidal statements, and act aggressively toward their self or others. These responses further distance the person from others, leaving them feeling severely alone, more rigidly mistrustful, harder to reach with psychological interventions, and more seriously suicidal. If sufficient support is not infused, the feeling of aloneness proceeds to despair and can progress to the point that an intensively supportive holding environment such as hospitalization or heroic rescuing responses may be necessary to reconstitute connectedness and bring temporary relief.

Suicide Risk Assessment According to GPM Phenomenology of Core Borderline and Narcissistic Vulnerabilities

Table 1.

Suicide Risk Assessment According to GPM Phenomenology of Core Borderline and Narcissistic Vulnerabilities

GPM'S Anti-Suicide Strategies for BPD

Suicide prevention strategies in GPM are matched to shifting states of interpersonal connectedness.20 Helpful responses when patients enter a threatened state include demonstrating empathic concern, identifying precipitating interpersonal events, challenging distorted perspectives, and coaching effective strategies to preserve valued support. At this stage, distinguishing nonsuicidal and nonserious self-harm from behavior that is suicidal in intent or medically dangerous can help prevent overly reactive and unnecessary hospitalization.

As people become more distanced from support, they feel more disconnected and more definitively alone. In this state, they become more seriously suicidal or dangerously self-harming, and less accessible through psychological interventions. Effective interventions are more concrete and include case management strategies, pharmacotherapy (eg, low-dose antipsychotics targeting dissociation, anger, paranoia, impulsivity), and rapid infusions of support, which might include escalating the level of care to intensive outpatient or partial hospitalization.31 In the despairing state, the “container” of inpatient hospitalization may be needed to facilitate the “cooling off” of intense affect surrounding suicidal crisis, identifying and addressing precipitants, and reevaluating the treatment frame with the inpatient team and outside consultants.

Once a sense of feeling connected is (temporarily) restored, clinicians should resume work on GPM's longer-term treatment goals. These are organized around building a more independent, functional, and meaningful life outside of treatment settings, thereby diminishing sources of dysphoria and suicide risk over time. Pertinent goals include establishing a realistic and satisfying social or vocational role, building new friendships and community supports to reduce unsustainable dependency on select supports, and, for some, achieving a romantic partnership.

General Features of Suicidality in NPD

NPD refers to a specific syndrome of certain personality characteristics, whereas the broader concept of pathological narcissism (PN) comprises a wider spectrum of vulnerabilities in self-esteem regulation. The wish to die can emerge acutely in a patient with NPD/PN without any preceding depressive state, disclosure of distress, or any overt red flags, resulting in “death without warning.”32–34 Serious suicidal intent is more common in patients with NPD/PN than in BPD. Suicidal behavior in NPD/PN tends to be rapid but well planned and well executed (rather than impulsive), highly lethal, and associated with a low subjective sense of distress due to dissociation, meaninglessness, or a high sense of agency and control.35 Acute suicidality emerging suddenly in response to unforeseen or intolerable life events should be distinguished from chronic suicidality, which in NPD/PN typically serves distinct “life-sustaining,” self-protective functions such as reasserting control over self (by imagining an escape hatch that is ever present and within easy reach) or control over others (by thwarting those motivated to prevent suicide).36,37

Acute suicide risk in NPD/PN is often driven by “narcissistic injuries,” which are life events prompting intense shame to the point where suicide becomes the only imaginable escape from an increasingly intolerable sense of entrapment, dishonor, or defeat. Shame generally results from a negative evaluation of the self that is prompted by a perceived failure.38 Shame proneness is generally associated with suicidality and self-harm, and may specifically mediate suicide-related behavior in NPD/PN.39–41 However, internal shame in PN is typically higher than externally expressed shame, such that critical internal processes precipitating suicidal behavior are typically hidden from plain view.40 Clinicians should be on alert that external signals often do not accurately convey internal states pertinent to the management of NPD/PN. It is imperative to establish a therapeutic relationship that promotes awareness and tolerance of shame and helps patients anticipate life events likely to precipitously escalate shame and suicide risk.

GPM'S “Intrapsychic Coherence” Phenomenology of Suicidality in NPD

Although GPM's interventions for NPD/PN lack direct evidence for efficacy, they follow a coherent, empirically informed, and clinically pragmatic phenomenology outlined in Table 1.42 This model is grounded in a core vulnerability of self-esteem dysregulation. In this model, shifts in inner experience, outward behavioral presentation, and acuity of suicide risk reflect the influence of life events triggering fluctuations in self-esteem. Life events significantly influence functioning and suicide risk in NPD/PN. Life events especially associated with suicide attempts in NPD include major work setbacks (eg, being fired), facing foreclosure on a mortgage or loan, mounting marital conflict, serious personal injury or medical illness, drastic or unexpected changes, loss of long-cherished hopes and dreams, and loss of valued others who served “self-object” functions of externally supporting a person's self-esteem.33,34,43 GPM posits that what these disparate destabilizing life events have in common is a real or perceived threat to self-esteem and control.

GPM's schematic of “intrapsychic coherence” organizes helpful interventions for NPD/PN according to four different levels of self-esteem. When self-esteem is compensated, suicide risk is low because the patient's sense of self and of being in control are relatively unchallenged. Patients seem self-sufficient and perhaps even highly functional. They are shielded from psychiatric symptoms, partly through disconnection from emotions in themselves or others. Alternatively, they may be aware of diffuse existential distress but remain unmotivated or unwilling to examine its sources. Envy is often present but not openly discussed. When the patient becomes threatened by real or perceived challenges to self-esteem or control, distress escalates but may remain hidden behind self-enhancing behavior to deflect experiences of vulnerability. These include overt grandiosity, boasting, devaluing others, and enacting superiority and specialness to promote “living up” to standards by self or others. These self-protective behaviors push others away, leaving the patient withdrawn from needed supplies of positive regard from others. Retreat into paranoia or paralysis may seal off threatening real-world expectations and demands, but also constructive support and appreciation from others. This state progresses into a despairing mentality when patients definitively lose hope and disinvest from trying to ever recover self-esteem. Previous efforts to “live up” to standards set by self or others give way to an ultimate choice to “give up” and act to escape a seemingly irreparably damaged sense of self.

One pathway for reconstituting self-esteem is through self-enhancing behaviors that elicit admiration or external validation from others and assert an idealized view of one's own achievements and attributes. At times self-esteem is restored through covertly grandiose assertions, which can take the form of being “best” at being the worst. A second compensatory mechanism is to put more distance between the self and the intrusions of reality by removing or diminishing environmental stressors and disinvesting from roles in which failure or imperfection is feared. Clinicians can foster a healthier approach to stabilizing self-esteem and countering harsh self-criticism over time by explicitly noticing both the real attributes and real struggles of the patient in a way that is recognized by the patient as genuine.

GPM'S Anti-Suicide Strategies for NPD

Suicide prevention strategies in GPM are matched to oscillating levels of self-esteem.42 In compensated states when subjective distress is barely perceptible, GPM proposes that clinicians capitalize on confidence in self to encourage self-inquiry and deepen attunement to compartmentalized and hidden emotional experiences such as shame, vulnerability, and fear of change. Gradually, clinicians cultivate a deeper shared view of presenting problems. A noninterpretive, nonjudgmental psychoeducational approach can help educate patients about challenges in self-esteem.

Psychological interventions at the threatened and withdrawn stages aim to capitalize on protective mechanisms for restoration of self-regard. After collaboratively identifying active threats to self-esteem, empathic and validating statements can help patients preserve or restore self-esteem, dignity, autonomy, and agency. The goal is not to merely agree, but to appreciate the difficulty patients are facing while valorizing the effort and courage required to face vulnerabilities and invoking opportunities for growth and mastery of self. Some patients may tolerate challenges to grandiose assertions or coaching around ways to restore or preserve positive regard from others. Once in the despairing state, patients become largely inaccessible to psychological interventions, and concrete case management and level-of-care interventions such as inpatient hospitalization aim to establish a safe container for the rebuilding of precarious self-esteem through temporary insulation from environmental stressors.

When self-esteem is restored to the compensated state, GPM interventions organize around long-term treatment goals for NPD/PN. These include setting and pursuing realistic (nongrandiose) academic and vocational goals, improving interpersonal dysfunction (by “getting a friend,” learning to collaborate, enhancing attention and emotional empathy toward others), and reducing overreliance on self by allowing others to begin to matter as valued peers and sources of support.

Conclusion

A GPM framework equips clinicians with a coherent, pragmatic approach for managing suicidality in BPD and NPD and in those with similar psychological vulnerabilities but not meeting full diagnostic criteria. Suicide crises are posited to arise from interpersonal disruptions in connectedness (in BPD) or intrapsychic disruptions in self-esteem (in NPD), which become targets for monitoring and intervention according to the current level of oscillation within core phenomenology.

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Suicide Risk Assessment According to GPM Phenomenology of Core Borderline and Narcissistic Vulnerabilities

Suicide RiskBPD's “Interpersonal Coherence” (Stages of Interpersonal Hypersensitivity)NPD's “Intrapsychic Coherence” (Stages of Self-Esteem Dysregulation)
LowConnected (“held” by an idealized, dependable relationship) BF: Idealizing, dependent ATI: Collaborative, but rejection-sensitiveCompensated (self-esteem bolstered against unwanted challenges) BF: Self-sufficient, unattuned to emotional interior of self and others, asymptomatic or only vaguely distressed, envious and wanting to be envied ATI: Accessible to interventions framed as enhancing agency, achievement, mastery
MediumThreatened (by real or perceived hostility, rejection, abandonment) BF: Angry, aggressive, devaluing, self-injurious, anxious ATI: Fragile, but help-seeking and accessible to expressions of concern and “leaning in” to enhance connectednessThreatened (by real or perceived loss of self-esteem, control, agency) BF: Frantic efforts to restore self-esteem: grandiose, self-enhancing, devaluing, entitled, demanding, aggressive, sadistic ATI: Fragile, but accessible to exploration and confrontation if buffered by ample validation, appreciation, admiration
HighAlone (after support is withdrawn) BF: Dissociated, paranoid, impulsive ATI: Mistrustful, help-rejecting, hard to reach but accessible through infusing concrete supportWithdrawn (after loss of positive self-regard within self or supplied by others, or loss of control or agency) BF: Insulating self from influence by others, retreating from life pursuits, paralyzed, paranoid ATI: Intolerant of alternate perspectives, but open to validation, agreement, appreciation, admiration
SevereDespairing (bereft of any holding relationship) BF: Suicidal, anhedonic ATI: Unreceptive to psychological interventions; often requiring hospital level of careDespairing (depleted, defeated, failed, devoid of hope for recovery of positive self-regard or control) BF: Hopeless, seriously suicidal, ready to “give up” after perceived failure to “live up” to standards ATI: Alienated; often requiring hospital level of care
Authors

Brandon T. Unruh, MD, is the Director, Mentalization-Based Treatment Clinic, and the Medical Director, Gunderson Residence, Gunderson Personality Disorders Institute, McLean Hospital; and an Instructor in Psychiatry, Harvard Medical School.

Address correspondence to Brandon T. Unruh, MD, McLean Hospital, 115 Mill Street, Belmont, MA 02478; email: bunruh@partners.org.

Disclosure: The author has no relevant financial relationships to disclose.

10.3928/00485713-20200310-03

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