Psychotherapy for suicidal patients with borderline personality disorder: an expert consensus review of common factors across five therapies

The objective was to review established literature on approaches to the psychotherapy of borderline personality disorder with specfic reference to suicide in order to determine if there were common factors across these efforts that would guide future teaching, practice and research. The publications from the proponents of five therapies for the treatment of suicidal behavior in individuals with borderline personality disorder (BPD), were reviewed and discussed by the members of the Group for the Advanced of Psychiatry, Psychotherapy Committee (GAPPC). Twenty nine published research and summary reports were reviewed of the specific treatments noted above along with two other reviews of common factors for this group of treatments. We used expert consensus as to the salient articles for review and the appropriate level of abstraction for the common factor definition. We formulated a definition of effectiveness and identified six common factors: 1) negotiation of a specific frame for treatment, 2) recognition and insistence on the patient’s responsibilities within the therapy, 3) provision to the therapist of a conceptual framework for understanding and intervening, 4) use of the therapeutic relationship to engage and address suicide, 5) prioritization of suicide as a topic to be actively addressed whenever it emerges, and 6) provision of support for the therapist in the form of supervision, consultation or peer support. We discuss common factors, their formulation, and implications for development and teaching of psychotherapeutic approaches specific to suicide in patients with borderline personality disorder and note that there should be greater attention in practice and education to these issues

Affective lability and difficulties with regulation are differentially associated with amygdala and prefrontal response in women with Borderline Personality Disorder

The present neuroimaging study investigated two aspects of difficulties with emotion associated with Borderline Personality Disorder (BPD()): affective lability and difficulty regulating emotion. While these two characteristics have been previously linked to BPD symptomology, it remains unknown whether individual differences in affective lability and emotion regulation difficulties are subserved by distinct neural substrates within a BPD sample. To address this issue, sixty women diagnosed with BPD were scanned while completing a task that assessed baseline emotional reactivity as well as top-down emotion regulation. More affective instability, as measured by the Affective Lability Scale (ALS()), positively correlated with greater amygdala responses on trials assessing emotional reactivity. Greater difficulties with regulating emotion, as measured by the Difficulties with Emotion Regulation Scale (DERS()), was negatively correlated with left inferior frontal gyrus (IFG()) recruitment on trials assessing regulatory ability. These findings suggest that, within a sample of individuals with BPD, greater bottom-up amygdala activity is associated with heightened affective lability. By contrast, difficulties with emotion regulation are related to reduced IFG recruitment during emotion regulation. These results point to distinct neural mechanisms for different aspects of BPD symptomology

The Zero Suicide Model: Applying Evidence-Based Suicide Prevention Practices to Clinical Care

Suicide is reaching epidemic proportions, with over 44,000 deaths by suicide in the US, and 800,000 worldwide in 2015. This, despite research and development of evidence-based interventions that target suicidal behavior directly. Suicide prevention efforts need a comprehensive approach, and research must lead to effective implementation across public and mental health systems. A 10-year systematic review of evidence-based findings in suicide prevention summarized the areas necessary for translating research into practice. These include risk assessment, means restriction, evidence-based treatments, population screening combined with chain of care, monitoring, and follow-up. In this article, we review how suicide prevention research informs implementation in clinical settings where those most at risk present for care. Evidence-based and best practices address the fluctuating nature of suicide risk, which requires ongoing risk assessment, direct intervention and monitoring. In the US, the National Action Alliance for Suicide Prevention has put forth the Zero Suicide (ZS) Model, a framework to coordinate a multilevel approach to implementing evidence-based practices. We present the Assess, Intervene and Monitor for Suicide Prevention model (AIM-SP) as a guide for implementation of ZS evidence-based and best practices in clinical settings. Ten basic steps for clinical management model will be described and illustrated through case vignette. These steps are designed to be easily incorporated into standard clinical practice to enhance suicide risk assessment, brief interventions to increase safety and teach coping strategies and to improve ongoing contact and monitoring of high-risk individuals during transitions in care and high risk periods

Adverse Childhoold Experiences and Sucidal Behavior

Early experiences of physical and sexual abuse are well-documented correlates of suicidal behavior in adolescence and adulthood. Childhood abuse and neglect have also been reported as etiological factors in the development of suicidal and self-harm behavior. There is evidence that adverse childhood experiences are related to the development of certain personality traits that increase the risk for suicidal behavior. Genetic and biological studies of the relationship between adverse childhood experiences and the serotonergic system, the opioid receptor system, and gene methylation identify possible biological mediators between environmental factors and personality traits related to suicidal behavior. In this article we revisit and update our 2008 review of what is known regarding the relationship and mediators between childhood abuse/neglect and suicidal behavior, while giving emphasis to the most recent findings. We integrate past and present findings into a theoretical model that illustrate current state of understanding as to how childhood adversity and genetic/biological factors interact to affect neurobiological changes, which then lead to the development of personality traits correlated with suicidal behavior. Belastende livshendelser i barndommen og risiko for suicidal atferd Fysisk og seksuelt misbruk av barn har en veldokumentert sammenheng med suicidal atferd senere i livet. Slike sterke belastninger kan også gi opphav til utvikling av personlighetstrekk som øker risikoen for suicidal adferd. Genetiske og nevrobiologiske studier har påvist en rekke mulige biologiske faktorer som kan mediere sammenhengen mellom miljømessige forhold, personlighetstrekk og suicidal og selvskadende atferd. Denne artikkelen er en oppdatering av vår litteraturgjennomgang fra 2008 om hva vi vet om forholdet mellom misbruk og omsorgssvikt i barndommen og suicidal adferd og hva som medierer sammenhengen. Vi har lagt mest vekt på de nyeste funnene, men trekker inn både tidligere og nye funn i en teoretisk modell om hvordan belastende livshendelser i barndommen og genetiske/biologiske faktorer sammen påvirker nevrobiologiske forandringer, som igjen fører til utviklingen av personlighetstrekk korrelert med suicidal atferd

Creating Suicide Safety in Schools: A public health suicide prevention program in New York State

Suicide is a serious public health problem worldwide. The World Health Organization calls for collaboration among all sectors of society using a multi-tiered approach to address risk factors. Schools have played a central public health role in fighting infectious diseases, malnutrition, community violence, accidental injuries, and heart disease. Similarly, when it comes to youth suicide prevention, schools are critically important community institutions.Schools are central civic institutions for building the resilience and positive helping environment necessary for the prevention of suicide. In this paper we will describe a program called “Creating Suicide Safety in Schools” (CSSS), which was developed to address the need for more comprehensive and consistentsuicide prevention training for school settings. The CSSS provides aframework for integrating school-based suicide prevention best practices, and the program is being implemented and evaluated in New York State. We will outline the CSSS model, the workshop, and how it is disseminated. The CSSS Workshop has been offered to school personnel for more than five years andindividuals from several hundred schools have participated in this training opportunity. Preliminary findings of the program’s acceptability in terms of attitudes, knowledge, perceptions of administrative support, and sense of empowerment based on a survey of 93 participants, will be presented.Suicide is a serious public health problem worldwide. The World Health Organization calls for collaboration among all sectors of society using a multi-tiered approach to address risk factors. Schools have played a central public health role in fighting infectious diseases, malnutrition, community violence, accidental injuries, and heart disease. Similarly, when it comes to youth suicide prevention, schools are critically important community institutions. Schools are central civic institutions for building the resilience and positive helping environment necessary for the prevention of suicide. In this paper we will describe a program called "Creating Suicide Safety in Schools" (CSSS), which was developed to address the need for more comprehensive and consistent suicide prevention training for school settings. The CSSS provides a framework for integrating school-based suicide prevention best practices, and the program is being implemented and evaluated in New York State. We will outline the CSSS model, the workshop, and how it is disseminated. The CSSS Workshop has been offered to school personnel for more than five years and individuals from several hundred schools have participated in this training opportunity. Preliminary findings of the program’s acceptability in terms of attitudes, knowledge, perceptions of administrative support, and sense of empowerment based on a survey of 93 participants, will be presented

Affective lability and difficulties with regulation are differentially associated with amygdala and prefrontal response in women with Borderline Personality Disorder

The present neuroimaging study investigated two aspects of difficulties with emotion associated with Borderline Personality Disorder (BPD): affective lability and difficulty regulating emotion. While these two characteristics have been previously linked to BPD symptomology, it remains unknown whether individual differences in affective lability and emotion regulation difficulties are subserved by distinct neural substrates within a BPD sample. To address this issue, sixty women diagnosed with BPD were scanned while completing a task that assessed baseline emotional reactivity as well as top-down emotion regulation. More affective instability, as measured by the Affective Lability Scale (ALS), positively correlated with greater amygdala responses on trials assessing emotional reactivity. Greater difficulties with regulating emotion, as measured by the Difficulties with Emotion Regulation Scale (DERS), was negatively correlated with left Inferior Frontal Gyrus (IFG) recruitment on trials assessing regulatory ability. These findings suggest that, within a sample of individuals with BPD, greater bottom-up amygdala activity is associated with heightened affective lability. By contrast, difficulties with emotion regulation are related to reduced IFG recruitment during emotion regulation. These results point to distinct neural mechanisms for different aspects of BPD symptomology

Suicide attempters with Borderline Personality Disorder show differential orbitofrontal and parietal recruitment when reflecting on aversive memories.

Suicidal behavior and difficulty regulating emotions are hallmarks of Borderline Personality Disorder (BPD). This study examined neural links between emotion regulation and suicide risk in BPD. 60 individuals with BPD (all female, mean age = 28.9 years), 46 of whom had attempted suicide, completed a fMRI task involving recalling aversive personal memories. Distance trials assessed the ability to regulate emotion by recalling memories from a third-person, objective viewpoint. Immerse trials assessed emotional reactivity and involved recalling memories from a first-person perspective. Behaviorally, both groups reported less negative affect on Distance as compared to Immerse trials. Neurally, two sets of findings were obtained. The first reflected differences between attempters and non-attempters. When immersing and distancing, attempters showed elevated recruitment of lateral orbitofrontal cortex, a brain region implicated in using negative cues to guide behavior. When distancing, attempters showed diminished recruitment of the precuneus, a region implicated in memory recall and perspective taking. The second set of findings related to individual differences in regulation success - the degree to which individuals used distancing to reduce negative affect. Here, we observed that attempters who successfully regulated exhibited precuneus recruitment that was more similar to non-attempters. These data provide insight into mechanisms underlying suicide attempts in BPD. Future work may examine if these findings generalize to other diagnoses and also whether prior findings in BPD differ across attempters and non-attempters