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Volume 50, Issue 5, May 2021

Early identification of personality disorder: Helping to understand youth suicide risk

Michelle L Townsend    Karlen R Barr    Brin FS Grenyer   
doi: 10.31128/AJGP-08-20-5568   |    Download article
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General practitioners (GPs) caring for young people will have some on their caseload displaying overwhelming feelings, which may indicate suicide risk. Suicide is a leading cause of death in children and adolescents in Australia.1 Over time, the rates of suicide in individuals aged 10–17 years have increased, and young people are dying by suicide at younger ages.

The suicide phenomenon is complex, with a combination of environmental, biological and social risk factors posing significant risk.2 Risk factors that may predict suicide risk in young people include prior suicide attempts, exposure to suicide by others, self-harm, hopelessness, adverse childhood experiences, access to lethal means and lethality of previous attempts.2,3 In addition, personality disorder traits are predictive of suicide in young people.2,4 One study found that 55% of young people who died by suicide had a personality disorder or personality disorder traits.5 Consequently, we argue that personality disorder traits should receive particular attention from GPs as they point to greater suicide risks.

Identify emerging personality disorder

Psychiatric disorders are major risk factors for suicide in young people.2,6 Various disorders have been linked to suicide, including psychosis, bipolar disorder, substance misuse, eating disorder, depression, anxiety and personality disorder. For borderline personality disorder (BPD), recurrent suicidal behaviour and/or self-harm is one of the nine diagnostic criteria.7 Many individuals with BPD will attempt suicide, and a smaller but significant proportion (approximately 10% of individuals with BPD) will die by suicide.8,9 In a sample of adolescents with BPD, 76% had attempted suicide.4 The National Health and Medical Research Council (NHMRC) clinical practice guidelines recommend that young people with emerging personality disorder symptoms should be assessed for BPD and provided appropriate treatment.9 Unlike in the past, BPD can now be diagnosed in individuals prior to the age of 18 years, and early identification and diagnosis of BPD is recommended.7 However, health professionals can show reluctance to diagnose young people with BPD.10 This reluctance has potential to not only limit the types of services individuals can access, but also delay access to effective treatment,8,10 and it may increase the risk of suicide for this population.11,12 It is recommended that GPs screen for BPD and refer young people to adolescent psychiatric services for further assessment if BPD traits are present.9 There are several validated measures GPs can use to screen for BPD in adolescents, including the McLean Screening Instrument for BPD.13

Ask about suicide

GPs are often in contact with young people experiencing suicidal behaviour, although they may not screen for suicide risk.14 Asking about suicidality does not increase distress or suicidal tendencies; indeed, acknowledging and talking about suicidality may reduce suicidal ideation and increase help-seeking.15 GPs acknowledge that to maintain a therapeutic alliance, sensitivity and compassion are needed when asking young people questions about suicide.16 The maintenance of a strong therapeutic alliance may be assisted by asking questions in a conversational way rather than strictly filling out a form. However, for GPs who do not feel confident, there is a freely available evidence-based suicide risk screening tool consisting of four items suitable for youth populations (Appendix 1).14 While measures that assess for suicide are not always accurate, assessing risk using these methods is better than not assessing at all.14

Intervene

For young people who present with emerging personality disorder or suicidal behaviours, the interventions shown in Table 1 are based on the current evidence available regarding GP-delivered interventions for young people and adults. The recommended interventions are based on the NHMRC Clinical practice guidelines for the management of borderline personality disorder9 and the Royal Australian and New Zealand College of Psychiatrists (RANZCP) clinical practice guidelines for the management of deliberate self-harm.17 As indicated in the guidelines, the interventions require a coordinated response that engages the young person, their caregivers, and health and school professionals.

Table 1. General practitioner–delivered interventions for young people presenting with emerging personality disorder or a non-fatal suicide attempt
Presentation Interventions delivered by a general practitioner
Emerging personality disorder (based on National Health and Medical Research Council guidelines9) Complete a mental health assessment if person presents with self-harm, risk-taking behaviour or overwhelming feelings

Refer to youth mental health service if further assessment is required

Work with the person to develop a management plan

Refer to structured psychological therapy or youth mental health service and collaborate with the service

Treat any co-occurring mental health or physical health problems

Involve the person’s family in assessment, planning and treatment if appropriate
Non-fatal suicide attempt Assess for current risk, including self-harm and personality disorder traits9,17

Ask about crisis management strategies that have previously helped9

Support the person to cope with anxiety9

Encourage the person to find practical actions to respond to their challenges9

Identify and respond to possible exposure to suicide3

Coordinate appropriate support services, such as referral to emergency department or mental health services9,17

Treat mental health disorders and substance abuse, including consideration of pharmacotherapy9,17,18

Consider providing information about online and mobile telephone applications for the management of self-harm and suicide ideation, eg Calm Harm, distrACT, moodgym, Beyond Now19

Offer follow-up appointments9,17

Communicate with and liaise between mental health services, schools and families16,17

BPD is an important suicide risk factor to consider in young people. Given the complexity of identification and management of risk,15 it is important to enhance the skills and confidence of GPs regarding the assessment and management of suicide risk in young people for GPs to best support their patients.1,15 This article offers some ways that GPs can support and intervene with young people presenting with personality disorder traits. Through GPs’ responding to a young person with suicide risk in a compassionate and effective manner,16 and by youth mental health services, schools, other support agencies and families working collaboratively with GPs, we can reduce youth suicide.

Competing interests: BFSG is the director of the Project Air Strategy for Personality Disorders and receives funding from NSW Ministry of Health for the Project Air Strategy for Personality Disorders.
Provenance and peer review: Not commissioned, externally peer reviewed.
Funding: None.
Correspondence to:
mtownsen@uow.edu.au
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AdolescentMental healthPersonality disorderSuicidal ideationSuicide

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