A Still Haunting Suicide

I first saw him nearly thirty years ago while I was in my psychiatry residency. He was in his twenties but had already had dozens of psychiatric hospitalizations. He exhibited the signs of Borderline Personality Disorder, or BPD. His case was particularly severe, and the common understanding in the Department of Psychiatry was that there was little likelihood anyone was going to “cure” him. As my mentor told me, “He has been practicing his illness longer than you have been practicing medicine.” Still, I had the motivation and naiveté to think I could make a difference.  Besides, despite all the tumult he caused, there was something endearing about him. His red hair, freckles, and occasional impish smile gave him an innocent, boy next store look. At times, they obscured the torment in his mind.

Any psychiatrist who has ever encountered a patient with severe BPD recognizes it almost immediately. These are the patients who get under your skin. Their high emotionality, over-sensitivity and  unreasonable demands are frustrating and wearying. You can’t please them. As the saying goes, they demand that you, “Go away a little closer.” Yet, despite the ease with which the disorder is recognized, it’s cause and treatment have remained matters of controversy.

Like many, though not all diagnosed with BPD, he had suffered a bitterly cruel childhood. When he was 11 years old, his drunkard father slugged him in the stomach so hard that his spleen was ruptured. Emergency surgery was required.  After he left home, and his father was no longer there to abuse him, he abused himself. In one case, he was in our Emergency Department when he took a piece of glass from his pocket and sliced into himself deeply enough to sever an artery. It was a potentially life-threatening injury. However, while it seemed  a suicide attempt, the likelihood of dying from the injury while in the Emergency Department was virtually nil. Moreover, while he had come on his own for help, his bizarre behavior only generated anger  and resentment—rather than sympathy—from the staff that  was then obligated to go to extreme measures to save him. He did exactly the opposite of what he needed to do to help himself and improve his interactions with others. The act was the utterly senseless and self-defeating behavior that typified BPD.

Of course, people are complex, and conditions such as BPD can be complicated by other, co-morbid conditions.  I am certain this unfortunate man also suffered Post-traumatic Stress Disorder, or PTSD, from the terrible abuse he suffered as a child. Indeed, the ongoing torment and cruelty would likely have led to what is referred to as complex PTSD. Some—perhaps most—of the persistent anxiety, reactivity, erratic behavior, and deep distrust and ambivalence he had towards others was likely due to PTSD. Nonetheless, his annoying, erratic behaviors, and hybrid of antagonistic and clingy interactions with other people  so perfectly fit the pattern of BPD that other diagnoses were eclipsed.  Indeed, I don’t recall any other diagnoses even being entertained during his many admissions. The diagnosis of BPD had been placed upon him years before I ever saw him. It was given and it stuck. 

I had treated him several times on the inpatient ward. These  hospitalizations usually consisted in his attending group psychotherapy and having his never very effective medications switched around. Mainly, his hospitalizations served to keep him safe from himself during difficult times. He would eventually claim improvement, deny further thoughts of suicide and demand to leave, after which there would be no legal basis to keep him against his will. There was only so much we could do. Indeed, each time he left I had the strong sense that in a few weeks or months he would be back in the hospital under the same set of circumstances.

One morning, I started my on-call duty for Psychiatry. A doctor in the Emergency Department gave me his sign-off report on the psychiatric patients who had come in during the night. “By the way,” he added in closing, “one of your guys was brought in after he cut into his antecubital fossa with a razor blade. He must have bled out before they got to him. He was DOA. He was a frequent flyer, and I think you knew him.  He’s still in the bag in the back cubicle.” He struggled to dredge his overly tired memory for the dead man’s name and finally voiced a vague recollection of who he thought he was. The name didn’t ring a bell. Still, his insistence that I knew him nagged at me, and I went back to find out for myself.

The dead from the Emergency Department were placed into opaque zippered bags and wheeled to the morgue down the hall. When I entered the room, I saw the zippered bag with the bulk of a body inside it lying on a gurney. I saw no identification on it. It was odd how unzipping the bag seemed an intrusion. I had the irrational feeling of invading the dead man’s privacy. The skin on the arm that was revealed as I unzipped the bag was shockingly white from blood loss. It was the arm that had been cut on the inside crook of the elbow, the antecubital fossa.  The reflexive sense of physical pain I felt in seeing the gaping lethal wound was also irrational, as the individual was beyond pain. The zipper began about 9 inches from the end of the bag. Thus, even after the bag was unzipped, I had to slip the bag up and over the dead man’s head to reveal who he was. First, I saw red hair, and I had a disquieting feeling that I did know the man. Then I saw his face. It was not the name my colleague had given me. It was the young man with BPD I had helped treat many times before on the psychiatric ward. I was struck with a sense of shock and sadness. I also remember feeling angry at how senseless and stupid his suicide seemed. Oddly enough, it is theorized that sufferers of BPD are unable to feel genuine anger and thus make others angry to allow them to feel the emotion vicariously. I remember thinking it ironic that it was as if he were engaging in this so-called projective identification even after he was dead.

There is great variation in the severity of BPD. While suicide is always a danger, these attempts are often  desperate, angry, conflicted pleas to “Help me live!” Indeed, many suicides of patients with BPD are inadvertent. Certainly, he had been clever enough to have survived his many previous exercises in suicide brinkmanship.  However, deep, endless emotional pain can be withstood for only so long. There are things worse than death. Perhaps he had had enough. Now and then, I still think about him.

For any who are having suicidal thoughts, help is available. Share your thoughts and feelings with family or friends, and seek help from your health care provider. The National Suicide Hotline phone number is 988, and someone will answer to talk with you and guide you to help. Finally, I must note that in the intervening years, specific therapies such as Dialectic Behavioral Therapy, or DBT, have been developed that are uniquely helpful for those who suffer BPD. There is help for you.