Clinical challenges in the assessment and management of suicidal behaviour in patients with bordeline personality disorder.

Self-injurious and suicidal behaviours are highly prevalent in patients with borderline personality disorder (BPD) and the risk of completed suicide is high. Borderline patients often present with heterogeneous clinical pictures and widespread comorbidity complicating clinical assessments and management. This calls for increased efforts in systematic evaluation and monitoring of self-harming and suicidal behaviours; these behaviours should be addressed actively as high priority treatment targets. Early drop-out is common for BPD patients in treatment but is possible to counteract by fostering a strong therapeutic relationship through adopting a realistic, but consistent and supportive approach carefully avoiding reinforcement of suicidal behaviours. Suicidal crises should primarily be managed in an outpatient setting giving priority to keeping the patient safe adopting a safety plan procedure, while helping the patient as quickly as possible to return emotionally to a more acceptable level of arousal and mental functioning. Pharmacological treatments should primarily be used for management of comorbid conditions, but may possibly also be helpful when used to reduce specific symptoms such as anger, hostility and impulsivity. There is currently a range of different integrated short-term and long-term psychological treatments in different stages of development and some of them have been shown to be efficacious in reducing suicidal behaviours; notably dialectical behaviour therapy and mentalization-based therapy.