Worldwide, at least 800,000 people die by suicide every year, equating to approximately one death every 40 seconds (WHO, 2018). Psychiatric diagnoses, including borderline personality disorder (BPD), are readily cited as risk factors for suicide-related behaviour (i.e. thoughts of suicide, self-harm, attempted suicide, and death by suicide) (Soloff et al., 2000). BPD is a longstanding condition characterised by impulsive behaviour, affective instability, and dysfunctional interpersonal relationships (American Psychiatric Association, 1980). BPD and suicide attempts have both previously been examined as independent factors, that can serve as strong predictors for subsequent death by suicide (Castellví et al., 2017; WHO, 2018), however, our understanding of their relationship is scarce.
However, historically stigmatising conceptualisations of BPD, alongside the condition’s ambiguous and omnipresent nature, has led some mental health professionals to practice reticence in ascribing a diagnosis altogether (see Campbell et al., 2020 for a thorough review). Moreover, despite people diagnosed with BPD demonstrating a standardised mortality rate 45 times that of the general population (Chesney, Goowin, & Fazel 2014), BPD and its criteria are often overlooked during suicide risk assessments. Yen and colleagues, therefore, sought to investigate correlations between a diagnosis of BPD and its attributes, and prospective suicide attempts over a 10-year follow-up period to highlight the importance of including them in suicide risk assessments.
People diagnosed with ‘borderline personality disorder’ have a standardised mortality rate 45 times that of the general population.
Methods
The researchers conducted a prospective cohort study, collecting baseline information from 733 help-seeking patients (in-patients, partial, and outpatients) across the east coast of the United States. Those who met the diagnostic criteria for 1 of 4 personality disorders (PDs), (Schizotypal PD, Borderline PD, Avoidant PD, and Obsessive-Compulsive PD) were eligible to be enrolled in the study. The study excluded participation based on four particular criteria, including 1) acute substance intoxication or withdrawal; 2) active psychosis; 3) cognitive impairment; and 4), schizophrenia, schizophreniform, or schizoaffective disorder. Participants were assessed using semi-structured diagnostic interviews and various self-report measures at baseline, six months, one year, and then annually for the subsequent ten-year period. The baseline and follow-up data underwent multiple logistic regression analyses to extrapolate the influence of baseline demographic and clinical factors, including BPD and its associated criteria, on prospective suicide attempt(s).
Results
From the initial cohort (N=733), 701 participants attended at least one follow-up assessment over the subsequent 10-year period. Of the 701 participants, 447 (64%) were female, 488 (70%) were White, 527 (75%) were single, 433 (62%) were unemployed, and 512 (73%) had some form of a college education. Following regression analysis of baseline and follow-up data, even when controlling for demographic variables (sex, education, and employment) and other clinical conditions, BPD was the most consistently associated factor with attempted suicides over the ten-year follow-up. Interestingly, when covarying for other significant factors and BPD criteria, specific components of BPD emerged as independent criteria that were significantly correlated with prospective suicide attempts. These are identity disturbance, chronic feelings of emptiness, and frantic efforts to avoid abandonment.
Even when controlling for demographic variables and other clinical conditions, ‘borderline personality disorder’ was the most consistently associated factor with attempted suicides over the ten-year period.
Conclusions
Given the results of this study, Yen and colleagues argue that identity disturbance, chronic feelings of emptiness, and frantic efforts to avoid abandonment, are key components of BPD that confer a high probability of suicide attempts.
Identity disturbance, chronic feelings of emptiness, and frantic efforts to avoid abandonment, are key components of ‘borderline personality disorder’ that confer a high probability of suicide attempts
Strengths and limitations
Yen and colleagues certainly identified gaps in suicide prevention research and practice, and they structured their data analysis procedure in a manner that reduced the likelihood of portraying misleading results. The researchers planned to explore the correlation between BPD and its criteria, and prospective suicide attempts. To validate their conclusions, they made a choice to exclude participants based on confounding factors (acute substance intoxication or withdrawal; active psychosis; cognitive impairment; and schizophrenia, schizophreniform, or schizoaffective disorder). In addition, the researchers controlled for demographics, such as sex, education, and employment. All of which are already acknowledged as either psychiatric or sociodemographic risk factors for suicide-related behaviour (WHO, 2014; Beghi et al., 2013), and therefore, could have produced a spurious association between BPD, its criteria, and attempted suicide. By doing so, the researchers have reduced the likelihood of cofounding bias interfering with the validity of their findings (Ananth, Enrique, Schiterman, 2017).
However, during baseline data collection, all participants were recruited from the east coast of the United States. This brings into question whether the sample used in this study are ‘representative’ of the population. The United States, for instance, is characterised by regional variations in social and political factors, both of which are hypothesised to influence geographical differences in suicide-related behaviour across the country (Bartan, 2013; WHO, 2018). Thus, would the researchers have come to similar conclusions, with samples also diagnosed with BPD, in other regions of the US, between nations, and across cultures, where psychosocial risk factors may have higher or lower prevalence? Moreover, given the pervasiveness of suicide attempts in the ‘general population’, approximately 20 for every death by suicide (WHO, 2014), it could be reasonably argued, that a 10-year follow-up period using an entirely random sample, irrespective of a psychiatric diagnosis, could yield a high number of suicide attempts. The argument is reinforced if we consider the demographic of the sample used in the current research (i.e. 64% female, and 62% unemployed). Globally, suicide accounts for 71% of violent deaths amongst females (WHO, 2014), and unemployment is often attributed to suicide-related behaviour (WHO, 2018). Therefore, although the researchers incorporated a control group consisting of people diagnosed with MDD, incorporating a general population sample may have strengthened the premise that BPD and its criteria are distinct risk factors for suicide-related behaviour.
All participants were recruited from the East Coast of the United States – which brings into question how representative this sample are of the population.
Implications for practice
BPD, as noted in the introduction to this blog, is already recognised as a serious risk factor for suicide (i.e. Chesney, Goowin, & Fazel 2014). This does not undermine the research conducted by Yen and Colleagues; on the contrary, these findings reinforce the importance of considering a BPD diagnosis when assessing for suicide risk. In addition, the findings demonstrate a statistically significant relationship between BPD criteria (specifically: identity disturbance, chronic feelings of emptiness, and frantic efforts to avoid abandonment) with attempted suicide. Consequently, these components should not be overlooked in clinical suicide risk assessments. From a research perspective, this important investigation on the east coast highlights the need for the association of BPD criteria and suicide-related behaviour to be studied on a national level, to gauge the magnitude of this problem.
These findings reinforce the importance of considering a ‘borderline personality diagnosis’ when assessing for suicide risk.
Statement of interests
No conflicts of interest.
Links
Primary paper
Yen, S., Peters, J. R., Nishar, S., Grilo, C. M., Sanislow, C. A., Shea, M. T., … & Skodol, A. E. (2021). Association of borderline personality disorder criteria with suicide attempts: findings from the Collaborative Longitudinal Study of Personality Disorders over 10 years of follow-up. JAMA psychiatry, 78(2), 187-194.
Other references
Ananth, C. V., & Schisterman, E. F. (2017). Confounding, causality, and confusion: the role of intermediate variables in interpreting observational studies in obstetrics. American journal of obstetrics and gynecology, 217(2), 167-175.
American Psychiatric Association, A. (1980). Diagnostic and statistical manual of mental disorders (Vol. 3). Washington, DC: American Psychiatric Association.
Beghi, M., Rosenbaum, J. F., Cerri, C., & Cornaggia, C. M. (2013). Risk factors for fatal and nonfatal repetition of suicide attempts: a literature review. Neuropsychiatric disease and treatment.
Campbell, K., Clarke, K. A., Massey, D., & Lakeman, R. (2020). Borderline Personality Disorder: To diagnose or not to diagnose? That is the question. International journal of mental health nursing, 29(5), 972-981.
Castellví, P., Lucas-Romero, E., Miranda-Mendizábal, A., Parés-Badell, O., Almenara, J., Alonso, I., … & Alonso, J. (2017). Longitudinal association between self-injurious thoughts and behaviors and suicidal behavior in adolescents and young adults: A systematic review with meta-analysis. Journal of affective disorders, 215, 37-48.
Chesney, E., Goodwin, G. M., & Fazel, S. (2014). Risks of all‐cause and suicide mortality in mental disorders: a meta‐review. World psychiatry, 13(2), 153-160.
Macdonald-Hart, S. (2020). Suicide prevention gatekeeper training and its long-term efficacy #WSPD2020. The Mental Elf, September 2020.
Soloff, P. H., Lynch, K. G., Kelly, T. M., Malone, K. M., & Mann, J. J. (2000). Characteristics of suicide attempts of patients with major depressive episode and borderline personality disorder: a comparative study. American Journal of Psychiatry, 157(4), 601-608.
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