Crisisinterventie bij suïcidale patiënten met een Borderline persoonlijkheidsstoornis. Cindey sijlbing

PICO P: Borderline persoonlijkheidsstoornis & acute suïcidaliteit I: Opname C: Treatment as usual (TAU) O: suïcide, frequentie TS, heropname

Gevonden publicaties RCT: nul Opname (crisis) afdeling: 1 (1997) Opname + psychotherapie: 1 (2010)

(1/5)Achtergrond Suïcide percentage 10% TS & suïcidale uitingen 20+ Geslaagde suïcide komt later Moeilijk te voorspellen “TS-er”: jong, vrouw, in zorg “suicide pleger”: ouder, man, niet in zorg Is hospitalisation usefull for patients with borderline personality disorder? Paris, 2004

(2/5)Crisis beds: the interface between the hospital & the community, Ash et al 1997 Persoonlijkheids- of aanpassingsst. Gemiddelde opnameduur 3 dgn 77% ontslag na crisisopname Heropname: 18% Follow-up 6 mnd

BPS ptn op SEH ivm “self-harm” Naturalistisch N= 200 (3/5)Crisis intervention at the general hospital: an appropriate treatment choice for acutely suicidal bordeline patients. Berrino et.al, 2010 (article in press) Opzet: BPS ptn op SEH ivm “self-harm” Naturalistisch N= 200 5 dgn intensieve behandeling vs TAU 3 mnd follow-up

“survival” tot TS: 85.6 vs 79.8 dgn Opname Ψ ZH: 8% vs 56% (4/5) Uitkomst: Recidief TS: 8% vs 17% “survival” tot TS: 85.6 vs 79.8 dgn Opname Ψ ZH: 8% vs 56% “survival” tot opname: 81.1 vs 42.2 dgn

NVvP Conclusie (2008): APA (2001) (5/5)Richtlijnen: De werkgroep is van mening dat, in geval van crisis met impulsief en suicidaal gedrag, kortdurende opname met een vooraf overeengekomen doelstelling de voorkeur heeft boven een langdurende opname. APA (2001) Take suicide threats seriously and address them with the patient. Taking action (e.g., hospitalization) in an attempt to protect the patient from serious self-harm is indicated for acute suicide risk.

Conclusie Geen evidentie voor opname reguliere afdeling Korte klinische behandeling?

NVvP richtlijn (crisisinterventie): 1.Intensivering van zorg. Goede empirische studies naar het effect van intensievere zorg, met name acute opname, ontbreken. In enkele studies wordt het positieve effect van een kortdurende opname, soms op initiatief van de patiënt, omschreven (25 89 355 402 ). 2. Groepsvaardigheidstraining. Een verkorte versie van dialectische gedragstherapie (DGT) was effectief in het verminderen van depressiviteit en hopeloosheid bij patiënten met een borderlinepersoonlijkheidsstoornis in crisis, in een niet-gecontroleerde studie (426 ). Conclusie:   De werkgroep is van mening dat, in geval van crisis met impulsief en suicidaal gedrag, kortdurende opname met een vooraf overeengekomen doelstelling de voorkeur heeft boven een langdurende opname.

25 - Ash Ash, D. , & Galletly, C. (1997) 25 - Ash Ash, D., & Galletly, C. (1997). Crisis beds: the interface between the hospital and the community. International Journal of Social Psychiatry, 43, 193-198. 89 - Breslow Breslow, R.E., Klinger, B.I., & Erickson, B.J. (1993). Crisis hospitalization on a psychiatric emergency service. General Hospital Psychiatry, 15, 307-315. 355 - Krawitz Krawitz, R., Jackson, W., Allen, R., e.a. (2004). Professionally indicated short-term risk-taking in the treatment of borderline personality disorder. Australasian Psychiatry, 12, 11-17. 402 - Little Little, J., & Stephens, D. (1999). A patient-based voucher system of brief hospitalisation. Australian and New Zealand Journal of Psychiatry, 33, 429-432.

APA guideline, suicide risk management The following are risk management considerations for suicidal behavior in patients with borderline personality disorder: Monitor patients carefully for suicide risk and document this assessment; be aware that feelings of rejection, fears of abandonment, or a change in the treatment may precipitate suicidal ideation or attempts. Take suicide threats seriously and address them with the patient. Taking action (e.g., hospitalization) in an attempt to protect the patient from serious self-harm is indicated for acute suicide risk. Chronic suicidality without acute risk needs to be addressed in therapy (e.g., focusing on the interpersonal context of the suicidal feelings and addressing the need for the patient to take responsibility for his or her actions). If a patient with chronic suicidality becomes acutely suicidal, the clinician should take action in an attempt to prevent suicide. Actively treat comorbid axis I disorders, with particular attention to those that may contribute to or increase the risk of suicide (e.g., major depression, bipolar disorder, alcohol or drug abuse/dependence). If acute suicidality is present and not responding to the therapeutic approaches being used, consultation with a colleague should be considered. Consider involving the family (if otherwise clinically appropriate and with adequate attention to confidentiality issues) when patients are chronically suicidal. For acute suicidality, involve the family or significant others if their involvement will potentially protect the patient from harm. A promise to keep oneself safe (e.g., a "suicide contract") should not be used as a substitute for a careful and thorough clinical evaluation of the patient's suicidality with accompanying documentation. However, some experienced clinicians carefully attend to and intentionally utilize the negotiation of the therapeutic alliance, including discussion of the patient's responsibility to keep himself or herself safe, as a way to monitor and minimize the risk of suicide.