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Euthanasia and assisted suicide of persons with psychiatric disorders: the challenge of personality disorders

  • Marie E. Nicolini (a1) (a2), John R. Peteet (a3), G. Kevin Donovan (a4) and Scott Y. H. Kim (a2)



Euthanasia or assisted suicide (EAS) for psychiatric disorders, legal in some countries, remains controversial. Personality disorders are common in psychiatric EAS. They often cause a sense of irremediable suffering and engender complex patient–clinician interactions, both of which could complicate EAS evaluations.


We conducted a directed-content analysis of all psychiatric EAS cases involving personality and related disorders published by the Dutch regional euthanasia review committees (N = 74, from 2011 to October 2017).


Most patients were women (76%, n = 52), often with long, complex clinical histories: 62% had physical comorbidities, 97% had at least one, and 70% had two or more psychiatric comorbidities. They often had a history of suicide attempts (47%), self-harming behavior (27%), and trauma (36%). In 46%, a previous EAS request had been refused. Past psychiatric treatments varied: e.g. hospitalization and psychotherapy were not tried in 27% and 28%, respectively. In 50%, the physician managing their EAS were new to them, a third (36%) did not have a treating psychiatrist at the time of EAS request, and most physicians performing EAS were non-psychiatrists (70%) relying on cross-sectional psychiatric evaluations focusing on EAS eligibility, not treatment. Physicians evaluating such patients appear to be especially emotionally affected compared with when personality disorders are not present.


The EAS evaluation of persons with personality disorders may be challenging and emotionally complex for their evaluators who are often non-psychiatrists. These factors could influence the interpretation of EAS requirements of irremediability, raising issues that merit further discussion and research.


Corresponding author

Author for correspondence: Marie E. Nicolini, E-mail:


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Ayre, K, Owen, GS and Moran, P (2017) Mental capacity and borderline personality disorder. BJPsych Bulletin 41, 3336.
Bamelis, LL, Evers, SM, Spinhoven, P and Arntz, A (2014) Results of a multicenter randomized controlled trial of the clinical effectiveness of schema therapy for personality disorders. American Journal of Psychiatry 171, 305322.
Bateman, A and Fonagy, P (2009) Randomized controlled trial of outpatient mentalization-based treatment versus structured clinical management for borderline personality disorder. The American Journal of Psychiatry 166, 13551364.
Bateman, A and Fonagy, P (2015) Borderline personality disorder and mood disorders: mentalizing as a framework for integrated treatment. Journal of Clinical Psychology 71, 792804.
Bateman, AW, Gunderson, J and Mulder, R (2015) Treatment of personality disorder. Lancet (London, England) 385, 735743.
Berghmans, RLP, Huisman, J, Legemaate, J, Nolen, WA, Polak, F, Scherders, MJWT and Tholen, AJ (2009) Richtlijn verzoek om hulp bij zelfdoding door patiënten met een psychiatrische stoornis. De Tijdstroom, U.
Bernal, M, Haro, JM, Bernert, S, Brugha, T, de Graaf, R, Bruffaerts, R, Lepine, JP, de Girolamo, G, Vilagut, G, Gasquet, I, Torres, JV, Kovess, V, Heider, D, Neeleman, J, Kessler, R and Alonso, J (2007) Risk factors for suicidality in Europe: results from the ESEMED study. Journal of Affective Disorders 101, 2734.
Blikshavn, T, Husum, TL and Magelssen, M (2017) Four reasons why assisted dying should not be offered for depression. Journal of Bioethical Inquiry 14, 151157.
Cristea, IA, Gentili, C, Cotet, CD, Palomba, D, Barbui, C and Cuijpers, P (2017) Efficacy of psychotherapies for borderline personality disorder: a systematic review and meta-analysis. JAMA Psychiatry 74, 319328.
den Hartogh, G (2017) Stervenshulp holt zolgvuldigheidseisen uit. Medisch Contact 2017;02(07):3436.
Doernberg, SN, Peteet, JR and Kim, SY (2016) Capacity evaluations of psychiatric patients requesting assisted death in the Netherlands. Psychosomatics 57, 556565.
Gastmans, C (2018) Levenseindezorg voor niet-terminale patiënten met ernstige psychiatrische aandoeningen. Brussels: Zorgnet Icuro. Available at (Accessed July 2018).
Giourou, E, Skokou, M, Andrew, SP, Alexopoulou, K, Gourzis, P and Jelastopulu, E (2018) Complex posttraumatic stress disorder: the need to consolidate a distinct clinical syndrome or to reevaluate features of psychiatric disorders following interpersonal trauma? World Journal of Psychiatry 8, 1219.
Griffith, J, Weyers, H and Adams, M (2008) Euthanasia and Law in Europe. Portland, OR: Hart Publishing.
Groenewoud, JH, Van Der Heide, A, Tholen, AJ, Schudel, WJ, Hengeveld, MW, Onwuteaka-Philipsen, BD, Van Der Maas, PJ and Van Der Wal, G (2004) Psychiatric consultation with regard to requests for euthanasia or physician-assisted suicide. General Hospital Psychiatry 26, 323330.
Kim, SY, De Vries, RG and Peteet, JR (2016) Euthanasia and assisted suicide of patients with psychiatric disorders in the Netherlands 2011 to 2014. JAMA Psychiatry 73, 362368.
Kurniawan, C and van der Zwaard, R (2018) Euthanasie bij psychiatrie roept vragen op. Medisch Contact 2018;03(10):2224.
Kvarstein, EH, Pedersen, G, Folmo, E, Urnes, O, Johansen, MS, Hummelen, B, Wilberg, T and Karterud, S (2019) Mentalization-based treatment or psychodynamic treatment programmes for patients with borderline personality disorder – the impact of clinical severity. Psychology and Psychotherapy: Theory, Research and Practice 92, 91111.
Leichsenring, F and Leibing, E (2003) The effectiveness of psychodynamic therapy and cognitive behavior therapy in the treatment of personality disorders: a meta-analysis. American Journal of Psychiatry 160, 12231232.
Levenseindekliniek Available at (Accessed July 2018).
Linehan, MM, Tutek, DA, Heard, HL and Armstrong, HE (1994) Interpersonal outcome of cognitive behavioral treatment for chronically suicidal borderline patients. American Journal of Psychiatry 151, 17711776.
Linehan, MM, Comtois, KA, Murray, AM, Brown, MZ, Gallop, RJ, Heard, HL, Korslund, KE, Tutek, DA, Reynolds, SK and Lindenboim, N (2006) Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Archives of General Psychiatry 63, 757766.
McMain, SF, Links, PS, Gnam, WH, Guimond, T, Cardish, RJ, Korman, L and Streiner, DL (2009) A randomized trial of dialectical behavior therapy versus general psychiatric management for borderline personality disorder. American Journal of Psychiatry 166, 13651374.
Meuldijk, D, McCarthy, A, Bourke, ME and Grenyer, BF (2017) The value of psychological treatment for borderline personality disorder: systematic review and cost offset analysis of economic evaluations. PLoS ONE 12, e0171592.
Newton-Howes, G, Tyrer, P, Johnson, T, Mulder, R, Kool, S, Dekker, J and Schoevers, R (2014) Influence of personality on the outcome of treatment in depression: systematic review and meta-analysis. Journal of Personality Disorders 28, 577593.
O'Connor, RC, Wetherall, K, Cleare, S, Eschle, S, Drummond, J, Ferguson, E, O'Connor, DB and O'Carroll, RE (2018) Suicide attempts and non-suicidal self-harm: national prevalence study of young adults. BJPsych Open 4, 142148.
Oldham, JM (2006) Borderline personality disorder and suicidality. The American Journal of Psychiatry 163, 2026.
Oldham, J, Gabbard, G, Goin, M, Gunderson, J, Soloff, P, Spiegel, D, Stone, M and Phillips, K (2010) American Psychiatric Association (APA) Practice Guideline for the Treatment of Patients With Borderline Personality Disorder. Available at (Accessed January 2019)
Onwuteaka-Philipsen, B, Legemaate, J, van der Heide, A, van Delden, H, Evenblij, K, El Hammoud, I, Pasman, R, Ploem, C, Pronk, R, van de Vathorst, S and Willems, D (2017) Derde evaluatie Wet toetsing levensbeëindiging op verzoek en hulp bij zelfdoding. Den Haag: ZonMw.
Owen, GS, Richardson, G, David, AS, Szmukler, G, Hayward, P and Hotopf, M (2008) Mental capacity to make decisions on treatment in people admitted to psychiatric hospitals: cross sectional study. BMJ 337, a448.
RTE Regional Euthanasia Review Committees Annual Report (2014) Available at (Accessed July 2018).
RTE Regional Euthanasia Review Committees Annual Report (2017) Available at (Accessed July 2018).
Schuklenk, U and van de Vathorst, S (2015) Treatment-resistant major depressive disorder and assisted dying. Journal of Medical Ethics 41, 577583.
Snijdewind, MC, Willems, DL, Deliens, L, Onwuteaka-Philipsen, BD and Chambaere, K (2015) A study of the first year of the End-of-Life Clinic for physician-assisted dying in the Netherlands. JAMA Internal Medicine 175, 16331640.
Steinbock, B (2017) Physician-assisted death and severe, treatment-resistant depression. The Hastings Center Report 47, 3042.
Swenson, CR and Choi-Kain, LW (2015) Mentalization and dialectical behavior therapy. American Journal of Psychotherapy 69, 199217.
Swildens-Rozendaal, WJC and van Wersch, PJM (2015) Code of Practice. The Hague. Available at (Accessed July 2018).
Thienpont, L, Verhofstadt, M, Van Loon, T, Distelmans, W, Audenaert, K and De Deyn, PP (2015) Euthanasia requests, procedures and outcomes for 100 Belgian patients suffering from psychiatric disorders: a retrospective, descriptive study. BMJ Open 5, e007454-2014-007454.
Trimbos Institute (2008) Trimbos Netherlands Institute of Mental Health and Addiction, Multidisciplinaire Richtlijn Persoonlijkheidsstoornissen (Multidisciplinary Guideline Personality Disorders). Utrecht, the Netherlands.
Tyrer, P, Reed, GM and Crawford, MJ (2015) Classification, assessment, prevalence, and effect of personality disorder. Lancet (London, England) 385, 717726.
Van, HL and Kool, M (2018) What we do, do not, and need to know about comorbid depression and personality disorders. The Lancet. Psychiatry 5, 776778.
Van Wel, EB, Bos, EH, Appelo, MT, Berendsen, EM, Willgeroth, FC and Verbraak, MJPM (2009) De effectiviteit van de vaardigheidstraining emotieregulatiestoornis (vers) in de behandeling van de borderlinepersoonlijkheidsstoornis; een gerandomiseerd onderzoek. Tijdschrift voor Psychiatrie 51, 291301.
Vandenberghe, J, Titeca, K, Matthys, F, Van den Broeck, K, Detombe, T, Claes, S, De Fruyt, J, Hermans, M, Lemmens, G, Peeters, D and Van Buggenhout, R (2017) Hoe omgaan met een euthanasieverzoek in psychiatrie binnen het huidig wettelijk kader? Adviestekst van de Vlaamse Vereniging voor Psychiatrie (VVP) over te hanteren zorgvuldigheidsvereisten. (Accessed July 2018).
Verhofstadt, M, Thienpont, L and Peters, GY (2017) When unbearable suffering incites psychiatric patients to request euthanasia: qualitative study. The British Journal of Psychiatry: The Journal of Mental Science 211, 238245.
WHO (2001) World Health Organization; Department of Mental Health and Substance Dependence; Gender Disparities in Mental Health. Available at (Accessed July, 2018).
Zanarini, MC (2009) Psychotherapy of borderline personality disorder. Acta Psychiatrica Scandinavica 120, 373377.
Zanarini, MC, Frankenburg, FR, Reich, DB and Fitzmaurice, G (2012) Attainment and stability of sustained symptomatic remission and recovery among patients with borderline personality disorder and axis II comparison subjects: a 16-year prospective follow-up study. American Journal of Psychiatry 169, 476483.
Zimmerman, M, Chelminski, I, Young, D, Dalrymple, K and Martinez, J (2012) Does the presence of one feature of borderline personality disorder have clinical significance? Implications for dimensional ratings of personality disorders. The Journal of Clinical Psychiatry 73, 812.


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Euthanasia and assisted suicide of persons with psychiatric disorders: the challenge of personality disorders

  • Marie E. Nicolini (a1) (a2), John R. Peteet (a3), G. Kevin Donovan (a4) and Scott Y. H. Kim (a2)


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