Case Scenario

My last appointment of the week was a new patient presenting with menstrual cramps. Entering the examination room, I noted that the patient had dysmorphic facial features, hearing aids and a wandering eye. I noted crutches leaning against the wall. Her boyfriend sat silently next to her as she presented me with a list of 10 medications she was taking for chronic conditions, including four drugs for depression and anxiety, and a separate, longer list of drug allergies.

The patient immediately launched into a long, detailed psychiatric history and included particulars of multiple surgeries for congenital problems. She could not remember the names of any previous doctors or her treating psychiatrist. She also confided that she had tried to stab herself with a knife earlier in the day, and her boyfriend had wrestled the knife away from her. Her boyfriend did not seem to be disturbed by the incident and calmly confirmed her story.

I asked the couple if they felt that going home that evening was a safe move. The patient's boyfriend agreed to stay with her, but the patient said,“No, if I go home, I might try to hurt myself again tonight.” She refused to sign a contract for safety, yet when I mentioned admitting her to the hospital, she became agitated and moved toward me. She positioned herself uncomfortably close to me and screamed. She demanded answers to personal questions and accused me of being depressed.

I excused myself from the room to allow her to calm down and to collect my thoughts. My gut instinct told me that she had a borderline personality disorder and was at low risk of suicide. On the other hand, I didn't know her well, she was obviously mentally ill and I didn't have a promise from her that she wouldn't try to hurt herself. I sent her home but tossed and turned all night worrying if I had made a decision based on what was best for the patient or what was best for me.

Commentary

On rare occasions, it falls to the family physician to assess a patient's suicidality. Most people think of suicide occasionally—under some kinds of stress, it can cross anyone's mind that the world would be a better place without them in it. However, having the thought and following it through to its lethal conclusion are miles apart. Furthermore, not all persons who express suicidal intent are depressed, nor do they all necessarily want to end their lives. How can a clinician assess potentially suicidal patients?

Depressed and impulsive persons, substance abusers, schizophrenic persons and persons with a borderline personality disorder are most likely to threaten suicide.¹ Loss of interest in life, poor appetite, hypersomnia or insomnia, lethargy, and feelings of hopelessness and guilt are common in depressed states. Some distressed people do not recognize how depressed they are. When feelings of helplessness and despair are overwhelming, suicide may seem like the only viable option. Impulsive patients have little tolerance for frustration and poor anger control; they do not plan, and they may disregard their own safety and that of others. Mood altering substances such as alcohol, opioids, hallucinogens and sedatives alter a person's perceptions, impair judgment and may increase the tendency for suicide.

Schizophrenia is also a risk factor for suicide when accompanied by hallucinations, delusions and disorganized speech and behavior; suicide may occur in response to a voice telling the patient to kill himself or herself, or as a desperate attempt to get rid of the auditory command hallucinations.

Unstable and intense interpersonal relationships, affective instability, impulsivity, identity disturbance, recurrent suicidal threats or gestures, and self-mutilating behaviors are some of the hallmarks of persons with a borderline personality disorder. Such persons have a poor sense of self, leaving them at risk for disintegration into a psychotic-like state. Stressful experiences and the influence of mood-altering substances highlight this vulnerability and place them at risk for acting impulsively or making poor judgments.

A single event rarely causes a person to consider suicide, but a major loss (such as the loss of a loved one, a job, good health or money) may increase a person's risk for suicide. The anniversary of the death of a loved one, which may evoke the unconscious wish of reuniting with the deceased, may also increase suicidal intent.

Attempts at suicide are more common than successful suicides. Women make more suicidal gestures than men, but men are more successful. Men tend to use more violent means of suicide than women. The risk of successful suicide is greatest among older men who live alone, who suffer from serious health problems and who have made previous attempts at suicide.

People who do commit suicide may display warning signs, such as giving away valuable belongings or previous unsuccessful attempts.

If a patient tells you that he or she wants to kill himself or herself, find out the details. Asking the patient whether he or she has a suicide plan and what it is will not cause that person to become anxious. On the contrary, it will be a relief for the patient to tell you about it. The more specific the plan, the stronger the intent.

The intensity of the patient's suicidal ideation and the depth of his or her depression, the clarity and specificity of the plans, the availability of means, the complication of substance abuse and, on the other hand, the availability of social support and patient reliability must all be carefully assessed. In a patient who has a plan and the means, and has a poor social network and believes that suicide is the only option—if he or she cannot be relied on to complete an appropriate out-patient treatment plan—immediate hospitalization is warranted.

All suicide threats, attempts and gestures must be carefully evaluated. Not all self-destructive acts are suicidal. Some patients make such gestures as a cry for help, to show their anger at themselves, to obliterate depressed feelings or to manipulate and control other people. A physician who establishes a collaborative relationship with such patients will be most likely to succeed in treating them.

In the specific scenario given here, the questions become “How did this visit become so problematic for both the patient and the physician?” “What could have been done to prevent this from happening?” To understand how this examination fell apart, let us consider each person's part in the exchange.

It is significant that on this initial visit to a new physician, the patient immediately gave a rather extensive medical, surgical and psychiatric history. In addition to her history, the patient told this family physician that she had tried to stab herself earlier in the day and feared she would attempt to harm herself again if sent home that evening. Feeling anxious and overwhelmed, and wanting to help a distressed patient, the physician recommended hospitalization for her safety. Enraged by this recommendation, the patient verbally assaulted the physician, prompting the physician to leave the examination room to gather his thoughts. As an alternative to leaving the room, the physician could have said to the patient, “Let's all calm down and relax. Take a few deep breaths with me.” This is an ideal way for the physician to regain composure and organize his thoughts. Such a statement signals that the physician, not the patient, is in charge. In essence, the physician uses himself as a gauge: “If I am feeling frustrated and anxious by all that is happening here, I can be certain that the patient also is feeling this way.”

The patient is clearly distressed and wishes to be understood. It is helpful to allow her time to explain her thoughts. The physician might ask the patient to state, as succinctly as possible and within a given time, what is troubling her, with a remark such as, “You seem to have a lot on your mind. Why don't you take five minutes to tell me exactly what's troubling you.” Setting a time limit forces the patient to conceptualize her thinking and articulate the problem. After she does so, the physician should rephrase the patient's complaints for their mutual benefit. The patient will feel reassured that she has been understood, and the physician can address the symptoms and make appropriate treatment recommendations.

Many physicians are uncomfortable making a mental health referral, as evidenced by the tendency to underestimate psychiatric disorders in their patients.² This physician's anxiety manifested itself in a request for the name of the patient's current psychiatrist.

When the physician in this scenario suggested hospitalization, the patient became verbally abusive. The next appropriate step would be to pursue her reasons for refusing the suggestion of hospitalization. It seems likely that by asking the patient to explain her reluctance, she also would become involved in her own treatment, and the physician's recommendation that the patient seek admission at the nearest hospital may have a better chance of being accepted.³

Another significant party in this scenario is the patient's boyfriend. Because the physician allowed him to remain in the examination room, the boyfriend could become a resource to encourage the patient. If the boyfriend is involved, he may become an advocate for the physician's recommendations.

The physician's diagnosis is one of probable “borderline personality disorder.” There are other diagnoses to consider, however, including malingering, factitious disorder and somato-form disorder (based on her clinical presentation, her extensive list of medications and her medical and psychiatric history). The patient's inability to remember her physicians' names may indicate a cognitive deficit, dissociation, paranoia or even manipulation.

Remember that the family physician and the patient are not adversaries, but collaborators. If the physician can engage the patient, his or her treatment suggestions are more likely to be accepted. However, the family physician always has the option of referring such a patient to a psychologist who is trained to work with difficult and demanding patients.⁴