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To leave it all behind: factors behind parasuicide roads towards stability
Umeå University, Faculty of Medicine, Department of Clinical Sciences, Psychiatry.
2004 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

This study was motivated by encounters with persons with repeated suicidality in clinical psychiatry. Their suicide attempts are frequently regarded as manipulative, and the patients are often labelled a “borderline personality disorder”. They cause frustration and are sometimes met with repellent attitudes among clinicians, but clinical experience as well as research shows that their personal history regularly includes severe childhood trauma and often childhood sexual abuse.

The first part of the study was undertaken to investigate the frequency of borderline personality disorder among consecutive persons admitted to hospital after a suicide attempt, the experience of adverse life events among them and the motives for the act. The concept and definition of parasuicide was used as inclusion criterion. During the 10 months of the study 81% of all parasuicide inpatients gave their consent to partake, altogether 64 patients, 41 women and 23 men. Standardized instruments were used for assessment of personality disorders, and self-report questionnaires were used to investigate motives and adverse life events.

Seven years later, follow-up interviews were conducted with 51 of these persons, 32 women and 19 men. This second part of the study used qualitative methods in the form of thematic open-ended interviews to allow for the patients’ own descriptions of their suicidality and mental health in the years following the suicide attempt. The role of psychiatry in this process was one of the themes in the interview. Use of psychiatric treatment and support during the follow-up period was investigated through a review of the medical charts recorded at the psychiatric clinic.

The quantitative part of the study showed that among the parasuicide patients there was a considerable overrepresentation of borderline personality disorder, and that the frequency of adverse life events was much higher in this subgroup. The motives for the parasuicide did not differ between those with borderline personality disorder and the others. Childhood sexual abuse could be identified as the most important factor influencing suicidality and extent of psychiatric treatment after the index parasuicide.

The patients’ own descriptions in the follow-up interview were related to the theoretical perspectives of symbolic interactionism, therapeutic alliance, perception of difference, empowerment and the concept of modernity. In the narratives a picture emerges of a psychiatric health care that carries the potential to offer therapeutic relationships, but often fails in its aims. In therapeutic alliances built on personal relationships, characterized by close and frequent encounters and a focus not only the weaknesses but also the strengths of the patient, there was room for personal development. A reliance on therapeutic method instead of a therapeutic alliance with the patient and a lack of a collaborative perspective in therapeutic work set definite hindrances for the therapeutic process, according to the views of the patients.

Regardless of the severity of the life experiences and personality dimensions that had lead to the parasuicide, the core prerequisite for subsequent stabilisation was an orientation towards significant others that saw and supported the potential for change and helped redefine the situation. These significant others were sometimes found in the psychiatric health care services, but were mainly found outside of psychiatry.

The conclusions of the study are that there is a close correlation between repeated suicidality, borderline personality disorder, female gender and adverse events such as childhood sexual abuse, and that the repeated suicidality is better explained by adverse events such as childhood sexual abuse than by personality disorder. This background seriously challenges repellent attitudes towards these patients. The narratives of the patients pose definite challenges for the therapeutic community to embrace new ways to find working therapeutic alliances after a parasuicide, possibly based around perspectives of empowerment and mutuality. Identifying the processes that helps the person find “the difference that makes a difference” should be in focus of future psychiatric research and at the heart of psychiatric support and treatment after parasuicide, to enable the patients to find their own strengths and resources and in this way be able to leave it all behind.

Place, publisher, year, edition, pages
2004. , 103 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 925
Keyword [en]
parasuicide, motives, life events, childhood sexual abuse, borderline personality disorder
Research subject
Psychiatry
Identifiers
URN: urn:nbn:se:umu:diva-362OAI: oai:DiVA.org:umu-362DiVA: diva2:143249
Public defence
2004-12-03, Sal B, Tandläkarhögskolan, Norrlands Universitetssjukhus, Umeå, 09:00 (English)
Opponent
Available from: 2004-11-12 Created: 2004-11-12 Last updated: 2010-05-06Bibliographically approved
List of papers
1. Personality disorders in parasuicide
Open this publication in new window or tab >>Personality disorders in parasuicide
2001 (English)In: Nordic Journal of Psychiatry, ISSN 0803-9488, E-ISSN 1502-4725, Vol. 55, no 3, 163-167 p.Article in journal (Refereed) Published
Identifiers
urn:nbn:se:umu:diva-4235 (URN)10.1080/08039480152036038 (DOI)
Available from: 2004-11-12 Created: 2004-11-12 Last updated: 2010-09-23Bibliographically approved
2. Life events, motives and precipitating factors in parasuicide among borderline patients
Open this publication in new window or tab >>Life events, motives and precipitating factors in parasuicide among borderline patients
2004 (English)In: Archives of Suicide Research, ISSN 1381-1118, E-ISSN 1573-8159, Vol. 8, no 2, 153-162 p.Article in journal (Refereed) Published
Abstract [en]

The high prevalence of borderline personality disorder in parasuicide raises the question whether there are differences in motives, precipitating factors, and life events as compared to other clinical groups. Consecutive hospital admitted parasuicide patients were therefore investigated for personality disorders by a structured clinical interview (SCID-II), a structured interview concerning precipitating factors and a self-report questionnaire on motives and life events. Out of a total of 64 patients, 55% met the criteria for a borderline personality disorder. While the parasuicidal motives and precipitating factors did not differ between the borderline group and the others, the borderline group reported significantly more adverse life events. Our findings suggest that the overrepresentation of borderline personality disorder in parasuicide might be related to accumulated adverse life events rather than to manipulative motives.

Place, publisher, year, edition, pages
Dordrecht: Kluwer Academic Publishers, 2004
Keyword
borderline personality disorder, parasuicide, life events, motives, precipitating factors
Identifiers
urn:nbn:se:umu:diva-4236 (URN)10.1080/13811110490271001 (DOI)
Available from: 2004-11-12 Created: 2004-11-12 Last updated: 2011-05-17Bibliographically approved
3. Childhood sexual abuse predicts poor outcome seven years after parasuicide
Open this publication in new window or tab >>Childhood sexual abuse predicts poor outcome seven years after parasuicide
2004 (English)In: Social Psychiatry and Psychiatric Epidemiology, ISSN 0933-7954, E-ISSN 1433-9285, Vol. 39, no 11, 916-920 p.Article in journal (Refereed) Published
Abstract [en]

Background:   There is substantial empirical research linking borderline personality disorder with prolonged mental instability and recurrent suicidality. At the same time, a growing body of observations links borderline personality disorder to sexual abuse and other forms of abuse and trauma in childhood. The aim of this study was to investigate among patients admitted for parasuicide the predictive value for outcome 7 years after the parasuicide of a diagnosis of borderline personality disorder compared to the predictive value of a history of childhood sexual abuse.Methods:   Semi-structured interviews were conducted at the time of the index parasuicide, with follow-up interviews 7 years later. In addition, information was collected from medical records at the psychiatric clinic. A logistic regression analysis was used to assess the specific influence of the covariates borderline personality disorder, gender and reported childhood sexual abuse on the outcome variables.Results:   Univariate regression analysis showed higher odds ratios for borderline personality disorder, female gender and childhood sexual abuse regarding prolonged psychiatric contact and repeated parasuicides. A combined logistic regression model found significantly higher odds ratios only for childhood sexual abuse with regard to suicidal ideation, repeated parasuicidal acts and more extensive psychiatric support.Conclusion:   The findings support the growing body of evidence linking the characteristic symptoms of borderline personality disorder to childhood sexual abuse, and identify sexual abuse rather than a diagnosis of borderline personality disorder as a predictor for poor outcome after a parasuicide. The findings are relevant to our understanding and treatment of parasuicide patients, especially those who fulfil the present criteria for borderline personality disorder.

Keyword
borderline personality disorder, sexual abuse, suicidal ideation, parasuicide, follow-up
Identifiers
urn:nbn:se:umu:diva-4237 (URN)10.1007/s00127-004-0839-0 (DOI)
Available from: 2004-11-12 Created: 2004-11-12 Last updated: 2011-05-16Bibliographically approved
4. Patients’ experience of and views on psychiatric treatment after parasuicide: a seven year follow-up
Open this publication in new window or tab >>Patients’ experience of and views on psychiatric treatment after parasuicide: a seven year follow-up
(English)Article in journal (Refereed) Submitted
Identifiers
urn:nbn:se:umu:diva-4238 (URN)
Available from: 2004-11-12 Created: 2004-11-12 Last updated: 2011-05-16Bibliographically approved
5. Means for stabilisation after parasuicide: Patients’ experiences and views. Results from a seven year follow-up
Open this publication in new window or tab >>Means for stabilisation after parasuicide: Patients’ experiences and views. Results from a seven year follow-up
(English)Manuscript (preprint) (Other academic)
Identifiers
urn:nbn:se:umu:diva-4239 (URN)
Available from: 2004-11-12 Created: 2004-11-12 Last updated: 2010-09-23Bibliographically approved

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