In an intake session with her parents, Naomi, a 16-year-old female, reportedly left a suicide note and had scratches on her wrists. The parents report this is the second suicide threat from Naomi, both over boy drama at school. Naomi denies suicidal ideation or previous attempts. Parents report family history of completed suicide and mother reports history of suicide attempts. Parents also report that Naomi has lost weight, suffers from hypersomnia, and has fits of rage. Naomi denies any substance use and shows no signs of psychosis.
Parents report family history of completed suicide as well as previous suicide attempts from the mother. Naomi also has threatened a very specific plan for killing herself in the past—taking her father’s narcotic pain medication—though was intercepted by her friend and parents. Naomi also has reported mood instability and fear of rejection and abandonment by boys at school. Due to the familial history of completed suicide and previous suicide attempts, as well as her mood instability, Naomi is at severe risk of suicidality. The provisional diagnosis of Borderline Personality Disorder 301.83 (F60.3) and Rule Out Major Depressive Episode, Severe, Recurrent, with atypical features: 296.33 (F33.2) (American Psychiatric Association, 2013). Ten percent of those struggling with Borderline Personality Disorder complete suicide (Paris, 2019). Adolescents from families with parental disability are also overrepresented in those suffering from Borderline Personality Disorder, and as Naomi’s father is currently on disability this helps with differential diagnosis (Larrivee, 2013).
Dialectical Behavioral Therapy is currently the best practice treatment for Borderline Personality Disorder, even in adolescents (Larrivee, 2013). While hospitalization was the norm, it is now understood that outpatient treatment can manage suicidality (Paris, 2019). Brief hospitalization for near-lethal suicide attempts may be indicated to ensure safety (American Psychological Association, 2017), however, due to Naomi’s provisional diagnosis, a day treatment center specializing in Dialectical Behavioral Therapy is indicated. This would include individual therapy sessions, skills training groups, behavioral coaching via phone by the therapist, and team consultation meetings (Larrivee, 2013). Concurrently providing psychoeducation and interventions from polyvagal theory may also be indicated (Austin, Riniolo, & Porges, 2007). Learning about the biology of trauma and the neurobiology can help support Dialectical Behavioral interventions, especially the mindfulness-based interventions.
First line suicide prevention with the family would be removing access to the means in the house, monitoring communication, and watching for warning signs. Psychoeducation on suicide prevention in teens for the parents will help empower them to help Naomi stay safe at home (Paris, 2019).
Family Therapy is the second preventative strategy for adolescent suicide. Family therapy is important as the environment of the home is often a factor in the behaviors we see in Borderline Personality Disorder (Larrivee, 2013). Having the family be involved in skills groups as well as having family sessions to help validate parental feelings and increase communication within the family is important. As Larrivee says “assuming that the environment influences the genetic vulnerability in the expression of the disorder, an intervention at the family level might be protective” (2013, p. 177).
Naomi appears to be struggling with Borderline Personality Disorder or features of the disorder. This disorder is characterized by emotional dysregulation, relationship difficulties, and self-harm or suicidal ideation. Due to the number of risk factors in conjunction with her diagnosis, Naomi is at severe risk of a completed suicide. Day Dialectical Behavioral Therapy along with family therapy are indicated to mitigate suicide risk.
American Psychological Association. (2017). Ethical Principles of Psychologists and Code of Conduct.
Larrivee, M.-P. (2013). Borderline personality disorder in adolescents: the He-who-must-not-be-named of psychiatry. Dialogues in Clinical Neuroscience, 15(2), 171–179.
Paris, J. (2019). Suicidality in Borderline Personality Disorder. Medicina, 55(6), 223.
Austin, M. A., Riniolo, T. C., & Porges, S. W. (2007). Borderline personality disorder and emotion regulation: Insights from the Polyvagal Theory. Brain and Cognition, 65(1), 69-76.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5 ed.). Arlington, VA: Author.